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THE TREATMENT 

OF 

INFANTILE PARALYSIS 



LO VETT 



BY THE SAME AUTHOR 



LATERAL CURVATURE 

OF THE 

SPINE, AND ROUND SHOULDERS 

THEIR CAUSE, PREVENTION AND CURE 
BY GYMNASTIC EXERCISES 

Third Edition. Revised and Enlarged. 
With 171 Illustrations. Octavo; 
xi+213 pages. Cloth, $1.75 postpaid. 

P. BLAKISTON'S SON & CO. 
PHILADELPHIA 



THE TREATMENT 

OF 

INFANTILE PARALYSIS 



BY a/* 

ROBERT W. LOVETT, M. D. 

BOSTON 

JOHN B. AND BUCKMINSTER BROWN PROFESSOR OF ORTHOPEDIC SURGERY, HARVARD MEDICAL 

SCHOOL; SURGEON TO THE CHILDREN'S HOSPITAL, BOSTON; SURGEON-IN-CHIEF TO THE 

MASSACHUSETTS HOSPITAI SCHOOL, CANTON; CONSULTING ORTHOPEDIC SURGEON TO 

THE BOSTON DISPENSARY; MEMBER OF THE AMERICAN ORTHOPEDIC ASSOCIATION; 

CORRESPONDING MEMBER OF THE ROYAL SOCIETY OF PHYSICIANS, BUDAPEST; 

KORRESPONDIERENDES MITGLIED DER DEUTSCHEN GESELLSCHAFT FUR 

ORTHOPADISCHE CHIRURGIE, SOCIO DELLA SOCIETA ITALIANA DI 

ORTOPEDIA 



WITH 113 ILLUSTRATIONS 



PHILADELPHIA 

BLAKISTON'S SON & CO. 

1012 WALNUT STREET 



Itf 



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Copyright, 1916, by P. Blakiston's Son & Co. 



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AUG -4 I9I6 



THE MAPX.E PRESS YORK PA 



©CU437107 



TO THE 

ANONYMOUS DONOR 

WHOSE GENEROSITY MADE POSSIBLE THE 

STUDY AND TREATMENT OF INFANTILE PARALYSIS IN VERMONT 

AND TO THE 

STATE BOARD OF HEALTH 

WHICH SO EFFECTIVELY CARRIED OUT THE 
DESIGN OF THAT DONOR 



PREFACE 



The great prevalence of infantile paralysis in America since 
1907 has not only directed the attention of the medical pro- 
fession to the disease in a very practical way, but has led to a 
rapid advance in our knowledge of the affection and of its treat- 
ment. Indeed so rapid has been this progress, particularly on 
the therapeutic side, that it has not had time to find its way 
into text-books, but exists almost wholly in the fugitive period- 
ical literature. 

It is to meet the situation just described that this book has 
been written and it is concerned wholly with treatment except 
for a short introductory chapter dealing with other aspects of 
the disease in their bearing on treatment. This limitation was 
adopted because my experience has been chiefly in this depart- 
ment and because conditions are not yet sufficiently settled 
with regard to pathology, etiology, transmission, etc., to make 
it possible to write a book with any promise of permanence 
which should deal with the whole subject. 

The aim has been to present a practical, plain and perhaps 
rather elementary statement of the various therapeutic meas- 
ures which I believe to be the soundest and best, and although 
I have not hesitated to quote from the work of others the per- 
sonal point of view has been emphasized. 

It has seemed best to discuss the question of the operative 
treatment of the affection in a comprehensive way but not to 
attempt to write an operative surgery. In this section my 
personal experience is responsible for my comments on the rela- 
tive value of the different operations. 

It has seemed desirable also to dwell at some length on the 
subject of muscle training because all experienced surgeons are 
today agreed that the operative treatment of infantile paralysis 
should not be undertaken until at least two years after the onset 
and during these two years, when the most rapid progress is to 

vii 



V1U PREFACE 

be made, the treatment must needs be a non-operative one. 
As muscle training in my opinion constitutes the most impor- 
tant of the early therapeutic measures it has been somewhat 
emphasized. The material for the chapter on this subject has 
been furnished by my senior assistant in private practice, Miss 
Wilhelmine G. Wright, who has for some years devoted prac- 
tically her whole time to this department of physical thera- 
peutics and who has already published an article on the subject. 
I am greatly indebted to her for formulating for me the exer- 
cises and tests. Illustrations of some of the tests and exercises 
have been given with a view of making the text clearer. 

It is impossible for me to acknowledge my indebtedness to 
the many who have helped me in my work, directly and indi- 
rectly. The work in Vermont was done in connection with 
laboratory work under the charge of the Rockefeller Institute 
of New York and to Drs. Simon Flexner and Harold L. Amoss 
of that institution I am greatly indebted for much advice. To 
my colleagues in the Physiological Department of Harvard 
University and in the Children's Hospital of Boston I am under 
obligation for assistance in many directions always willingly 
given. I owe very much also to the State Board of Health of 
Vermont not only for the opportunity to study the great 
amount of clinical material in that state but for their continued 
cooperation and advice and interest at all times. This obliga- 
tion I have attempted to acknowledge in part by dedicating 
to them this book. To the many others who have helped me 
I offer my best thanks. 



CONTENTS 

Chapter Page 

I. Pathology — Symptoms and Types — Mortality — Diagnosis — 

Prognosis i 

II. Treatment — The acute phase — Serum and drugs — Rest — Quarantine 

— Prevention of deformity — Summary of treatment 29 

III. Treatment — The convalescent phase — Ambulatory treatment — 

Braces — Balance — Prevention of permanent deformity — Stages 
and varieties of deformity — Dislocations — Restoration of nerve 
and muscle power — Massage — Heat — Electricity — M u s c 1 e 
training 

IV. Treatment — The chronic phase — Shortening — Lameness — Correc- 

tion of deformity — Deformity at the ankle — Deformity at the 
knee — -Deformity at the hip — Scoliosis — Deformities of the up- 
per extremity 74 

V. Treatment — Operative — Operations to improve functions — Tendon 
transplantation — Nerve transplantation — Operations to improve 
stability — 'Arthrodesis — Substitutes for arthrodesis of the ankle 
— Silk ligaments — 'Tenodesis — Astragalectomy — Tendon short- 
ening — Summary of operative measures 96 

VI. Muscle training — Examination of muscles — Gait — Principles of mus- 
cle training — Exercises for examination and muscle training . . . 123 

VII. The spring balance muscle test 152 

Index ' 161 



IX 



TREATMENT OF INFANTILE PARALYSIS 

CHAPTER I 

PATHOLOGY— SYMPTOMS AND TYPES— MORTALITY— DIAGNO- 
SIS— PROGNOSIS 

The name infantile paralysis is used in this book to describe 
the affection under discussion because of the names in common 
use it seems the least objectionable. The name anterior polio- 
myelitis is incorrect for the reason that our better knowledge 
of the pathology has shown the cerebrum as well as the cord 
to be generally involved. The correct pathological name 
would be anterior poliomyeloencephalitis, which of course is 
impossible as a descriptive term. The name Heine-Medin dis- 
ease proposed by Wickman offers no advantages, and has not 
been much used, while the names essential paralysis of children, 
teething paralysis and the like are obsolete. The name infan- 
tile paralysis does not correctly describe the affection when it 
attacks adolescents and adults, but on the whole it seems the 
most available for general use. 

Infantile paralysis has in the last few years assumed a special 
importance on account of its increased frequency in America, 
as well as, to a less extent, its greater prevalence in certain 
foreign countries. 1 Although the disease was recognized and 
described by Heine in 1840, 2 it is only since 1907 3 that it has 
become a serious problem in America. In that year a great 
epidemic occurred in New York City, followed by a widespread 
prevalence throughout the United States and Canada, 4 so that 
now every year leaves behind it thousands of victims. 

1 Haglund Barnforlamnings foljderna och Devas Behundling, Stockholm, 

1913- 

2 Warner: "Die Heine Medin Krkt," Leipzig, Diss. Halle, 1913. 

3 "Epidemic Polyomyelitis," Report of Committee, etc. N. Y., 1910. 

4 "The Occurrence of Infantile Paralysis in the U. S. and Canada," " Am. 
Jour, of Dis. of Children," August, 191 1. 



2 TREATMENT OF INFANTILE PARALYSIS 

With this increased incidence of the disease there has come 
a new and better knowledge of its pathology, and especially of 
its treatment, which will be considered here. But as any sound 
treatment must be based on pathological data, it becomes 
important first to consider very briefly the pathology, in so far 
as it bears on treatment. 



PATHOLOGY 1 

Infantile paralysis is a general infection, the results of which 
are most marked in the nervous system. In the nervous sys- 
tem at autopsy the meninges are found to be edematous and 
injected and there is a slight increase in the amount of cerebro- 
spinal fluid. The brain and cord are edematous, and this is 
especially noticeable in the gray matter of the cord, which is 
darker than normal and often projects above the cut surface. 
Minute hemorrhages can generally be distinguished. 

It seems probable that the infection enters the body from the 
upper respiratory tract, but once entered it evidently does its 
damage by means of circulating in the blood-stream. The first 
change in the pathological process is an acute insterstitial men- 
ingitis, usually most marked on the anterior surface of the 
spinal cord. In the cord itself there occurs a hyperemia, 
and a collection of small round cells in the lymph spaces sur- 
rounding the vessels. In many places the cells are so 
numerous that they press on the lumen of the vessel and exert 
a mechanical effect in obstructing the circulation. Minute or 
extensive hemorrhages occur, and there is an extensive edema. 

These three factors, cellular exudate, hemorrhages and edema, 
appear to be the primary reaction of the nervous system to the 
virus of infantile paralysis. Because the virus reaches the 
nervous system through the blood-stream, the cervical and 
lumbar enlargements of the cord are most often affected, and 
the anterior horns more often than the posterior or the white 
matter, because in these regions the blood-supply is most 

1 This pathological information has been largely taken from the monograph 
of Peabody, Draper and Dochez. Rockefeller Institute, New York, 19 12 and 
from the article by Flexner, Clark and Amoss, "Jour, of Exp. Med.," 1914, No. 2. 



PATHOLOGY 3 

abundant. Although the process by which the vascular lesions 
affect the nerve cells is in large measure a mechanical one, it is 
impossible to exclude the fact that the virus may exert some 
directly toxic action on these cells, but whether or not this is 
the case, much of the trouble is to be explained by the circu- 
latory disturbance and the exudate. The damaging effects 
therefore are to be attributed in part to direct pressure on the 
nerve cells of hemorrhages, edema and exudate, to which must 
be added the anemia following the constriction of the blood- 
vessels and in addition to this may be the direct toxic action of the 
virus itself on the nerve cells. On account of this pressure and 
anemia the nerve cells degenerate, and if the hemorrhage and 
exudate are absorbed soon enough the cells may recover func- 
tion, but if the unfavorable conditions have been prolonged too 
long or are excessive, the nerve cells may go on to complete 
degeneration. 

In addition to changes in the spinal cord it is very important 
to note that the same sequence of changes, vascular disturbance, 
and subsequent degeneration of the nervous elements, is found 
to a less degree in the brain, medulla and pons, the two latter 
showing some slight degree of involvement in most cases and 
frequently a marked cellular exudate and many hemorrhages. 
It is often difficult to reconcile the clinical symptoms which are 
referable to lesions of the pons with the actual autopsy findings. 

The posterior root ganglia are practically always involved by 
lesions similar to those in the cord itself, and in experimental 
pathology this is the first step in the process. It is probable 
that the lesions in the sensory ganglia may to a greater or less 
extent account for the pain and tenderness which are almost 
constant features of the acute stage of the disease. 

The terminal stage in the pathological changes is represented 
by the replacement of the motor cells by cicatricial tissue, with 
shrinking of the whole anterior horn in severe cases. The 
destruction of spinal cells in any center naturally represents a 
loss of function of those cells, but the connections between the 
bundles of motor cells and the connections between muscles and 
the motor centers are so free and so manifold that unless the 
destruction has been very extensive, the possibility remains of 



4 TREATMENT OF INFANTILE PARALYSIS 

establishing new connections between the motor cells and 
muscles. 

The changes which are found in other organs in infantile 
paralysis are less striking than those of the nervous system, 
but are practically as constant, being shown as an extensive 
involvement of the lymphoid tissue and of parenchymatous 
organs. In the latter cloudy swellings are usually met with, 
not*unlike those of typhoid fever. 

In short, it must be remembered that infantile paralysis is 
a general toxemic process which affects organs throughout the 
body, but which apparently acts mildly, and on the other hand 
it is characterized by lesions in the spinal cord which occasion- 
ally prove fatal by involvement of the nerve cells controlling 
respiration; these changes generally lead to a greater or less 
impairment of motor function of certain of the cells controlling 
muscular action, most often in the legs. The great tendency 
toward spontaneous repair in this disease is explained by the 
pathology, which shows also why partial paralysis is so much 
more common than total. 

SYMPTOMS 

It will be necessary to summarize the symptoms in so far as 
they bear on the question of treatment. The symptoms are 
what one would expect from a consideration of the pathology — 
a scattered and widespread poliomyelo-encephalitis with men- 
ingeal complications. The clinical manifestation is a similarly 
widespread and scattered motor paralysis or weakening. 

There is, in the great majority of cases, nothing characteristic 
about the acute onset. The symptoms are in general those 
of an acute infection. In many instances, however, gastroin- 
testinal symptoms predominate, while in others those referable 
to the respiratory tract are the most marked. Sweating, marked 
nervous irritability and general hyperesthesia are present in 
many instances before the onset of the paralysis, but they are 
not at all constant. Their presence points toward this disease, 
but their absence does not count against it. 

The great majority of all cases are of the familiar and long 



TYPES 5 

recognized type to be briefly discussed later, but there are 
variations in the disease described by Wickman 1 as types, in 
which the symptoms are not of the usual kind, and this descrip- 
tion has aided us in recognizing the multiform character of the 
disease. Most of these types, as for instance, the ataxic form, 
are uncommon to say the least, but however uncommon some 
of these types may be, a great impetus was given to the intelli- 
gent study of the disease by Wickman's classification, and it 
was recognized that unusual localizations of the disease occa- 
sioned unusual symptoms. 

Wickman's classification is as follows: 

i. Ordinary spinal paralysis; anterior poliomyelitis. 

2. Progressive paralysis, usually ascending, less often de- 
scending; Landry's paralysis. 

3. Bulbar paralysis; polio-encephalitis of pons. 

4. Acute encephalitis; giving spastic mono- or hemiplegia. 

5. Ataxic type. 

6. Meningitic type. 

7. Polyneuritic (multiple neuritis) type. 

8. Abortive type. 

This classification is, however, objected to 2 as being compli- 
cated and based neither on pathological anatomy nor clinical 
symptomatology, and on the ground that the so-called types are 
not types but variations in symptomatology. 

The classification of Muller 3 is simpler: (1) The spinal form, 
(2) the bulbar form, (3) the cerebral form, and (4) the abortive 
cases. Peabody, Draper and Dochez advocate a simpler classi- 
fication still: (1) Abortive, (2) cerebral, where involvement of 
the upper neurone causes spastic paralysis, and (3) the bulbo- 
spinal group, where there is a lesion of the lower neurone with 
flaccid paralysis. 

The fact is that a diffuse and variable process, by affecting 
different parts of the nervous system, causes different symp- 
toms, and that no one classification will satisfactorily cover 

1 "Die Akute Poliomyelitis," etc., Berlin, 191 1. 

2 Peabody, Draper and Dochez: Monograph No. 4, Rockefeller Institute, 
1912. 

3 Miiller: '"Die Spinale Kinderlahmung," Berlin, 1910. 



6 TREATMENT OF INFANTILE PARALYSIS 

all cases. The references refer to unusual variations in the 
symptoms. 

Miiller: "Munch. Med. Wchsft.," Jan. 23, 191 2. 
Colliver: "journ. A.M. A.," Mar. 15, 1913. 
Wachenheim: "N. Y. Med. Journ.," Nov. 8, 1912. 
Frissell: "journ. A. M. A.," LVI, No. 9. 
Koplik: "Am. Journ. Med. Soc," June, 1911. 
Batten: "Journ. A. M. A.," LXII , No. 15, p. 1200. 
Pearson: "Birmingham Med. Review," Apr., 1910, p. 148. 

An attack apparently confers immunity although one or two 
instances have been reported where a second attack seems to 
have occurred. 

Ordinary Spinal Type. — It is unnecessary to take up in detail 
the symptoms of this, the common type, long recognized and 
described, but a summary of its features should be given. 
After an acute onset of greater or less severity a motor paralysis 
appears, reaching its maximum in the following period after 
the attack: 1 

Cases Per Cent. 

Same day., 95 16.12 

One day 93 15 . 78 

Two days 103 1 7 . 49 

Three days 98 16 . 63 

Four days 58 9 . 84 

Five days 22 3 . 73 

Six days 51 8.65 

From an analysis of 589 cases. 

Early symptoms frequently seen are feverishness, drowsiness, 
sweating, often gastro-intestinal symptoms, stiffness in the 
neck and back, difficulty with micturition or defecation. 2 
Sore throat, delirium and convulsions are other occasional early 
symptoms. 3 

The onset of the disease is accompanied by tenderness in the 
great majority of cases, which tenderness persists for from one 
week to two or three months and leads to many diagnostic 
errors. 

1 "Infantile Paralysis," R. W. Lovett and M. W. Richardson, "Am. Jour. of. 
Dis. of Children," December, 191 1, p. 369. 

2 F. R. Fraser: "Clinical Observations on Ninety Cases," etc., "Am. Jour. Med. 
Sci.," July, 1914. 

3 Lovett and Richardson: "Am. Jour, of Dis. of Children," December, 1911. 



DISTRIBUTION 7 

Following the development of the paralysis comes a stationary 
period, after which begins a spontaneous improvement in muscle 
power. This was formerly thought to last for about six months, 
but later observation has shown that it is by no means ended 
at the end of one year (Vermont figures). The final paralysis 
is, however, always less than the initial if the patient lives. 

The paralysis is more often partial than total, 1 1,452 affected 
muscles, 416 totally paralyzed, 1,136 retaining some degree of 
contractility (about 2.5 to 1). Estimated by the muscle- 
testing apparatus, to be spoken of later, which deals more with 
muscle groups and which detects more slightly affected muscular 
action, the proportion was about 9 to 1, 958 partially paralyzed 
groups and 1 1 1 totally paralyzed. 

Distribution and Severity. — Location. — In 251 Vermont 
cases of all ages and of all durations since the attack, none, 
however, of less than two months, a careful personal examina- 
tion gave the local distribution shown in the table. In 985 
cases from the Massachusetts figures collected from the physi- 
cians' reports dealing with both acute and subacute cases, this 
class being naturally less closely and accurately observed than 
the Vermont cases showed slightly differing figures which are 
added for comparison. The two groups agree fairly well in 
showing that the affection of one leg is the commonest type, 
followed by that of both legs. 



1 leg 

2 legs 

1 arm 

2 arms 

1 leg, 1 arm 

2 legs, 1 arm 

1 leg, 2 arms 

2 legs, 2 arms 

251 985 

The accompanying table gives the number of total paralyses 
of each muscle, the number of partial and total paralyses, and 

1 R. W. Lovett: "The Treatment of Infantile Paralysis," "jour. A. M. A.," 
June 26, 1915. 



Vermont 
Cases 


Massachusetts 
Cases 


95 


324 


73 


272 


21 


84 


4 


23 


16 


143 


14 




4 


IO 


14 


129 



8 



TREATMENT OF INFANTILE PARALYSIS 



the proportion of total to partial in each. These figures were 
obtained by recording the power of voluntary contraction in the 
muscles and rest on careful personal observations. 

Table i. — Degree of Affection of Individual Muscles 



Muscle 



Adductors 

Gluteals 

Flexors of hip 

Quadriceps 

Hamstrings, outer. . . . 
Hamstrings, inner. . . . 

Gastrocnemius 

Tibialis anticus 

Peroneals 

Deltoid 

Trapezius 

Infraspinatus 

Pectoralis 

Biceps 

Triceps 

Abdominal 

Latissimus dorsi 

Spinal 

Flexor carpi ulnaris . . 
Flexor carpi radialis. . 
Extensor carpi ulnaris 
Extensor carpi radialis 



Number 
Paralyzed 



68 

133 
81 

152 
97 
95 

128 

119 
96 
57 
49 
17 
29 
3i 
28 

79 
49 
40 
16 
16 

19 

18 

1,417 



Number 
Partial 



52 
106 

63 

119 

66 

73 
88 

53 
40 

45 
42 
8 
22 
24 
22 
64 
40 
36 
12 
11 
14 
13 



Number 
Complete 



16 

27 
18 

33 

3i 

22 

40 

66 

56 

12 

7 

9 

7 

7 

6 

15 
9 
4 
4 

5 
5 
5 

4 02 



Proportion 
of Partial 
to Total 






3.2:1 
3-9M 

3-5:i 
3.6:1 
2.7:1 
2.7:1 
2.2:1 
0.8:1 
0.7:1 

3-7:i 
6.0: I 
0.9: I 
3.1:1 

3-4=1 
3.6:1 

4.3:i 

3-4:i 
9.0:1 
3.0:1 
2.2:1 
2.8:i 
2.6: 1 



The main facts are that the quadriceps, gluteals and gastroc- 
nemius lead in frequency, and that paralysis of leg muscles is 
much more frequent than of arm muscles. Paralysis of the 
adductor of the thumb is extremely common. Abdominal 
paralysis existed in more than half of all the cases (seventy- 
nine), and affection of the muscles of the spine in more than a 
quarter (forty). The latter points have a distinct bearing on 
the occurrence of scoliosis, and indicate, apparently, that such 
affections are more common than had been supposed. The 
cases of abdominal paralysis were always symmetrical with 



DISTRIBUTION 9 

two exceptions, one right and one left. This paralysis may 
occur as the only peroeptible one in the entire muscular sys- 
tem. When associated with paralysis of other parts, the as- 
sociation was always with leg muscles. 

The tibialis anticus and gastrocnemius are the leg muscles 
most commonly found to be affected by themselves without 
paralysis occurring elsewhere in the body. Of the former 
muscle, there were five cases of paralysis, of the latter, three. 
Deltoid paralysis may occur alone in the arm. 

Fraser 1 has called attention to the frequency of involvement 
of the facial muscles in cases of the ordinary type of paralysis 
affecting the limbs, a fact generally not recognized. In a series 
of ninety cases thirty-one showed involvement of facial muscles. 
In five cases the facial muscles alone were involved while in 
the other twenty-six other parts of the body were also affected. 

In the lower extremity analysis shows that the paralysis is 
severest in the foot, next most severe at the knee and least 
severe at the hip while in the arm it is severest at the shoulder, 
lighter at the elbow and least severe in the hand. 2 

With regard to distribution of the motor disturbance, the 
more exact the method of examination the more will the clinical 
phenomena be found to correspond with the modern patho- 
logical findings from experimental and human post-mortem 
data. The muscle test to be described (page 152) shows that 
the distribution of trie paralysis is more widespread than 
ordinarily supposed and confirms the observation that the 
loss of motor function is much more often partial than total. 
The conception of the disease from these findings would rather 
indicate a general infection accompanied by a widespread and 
irregular loss of power, in most muscles of a mild grade. This 
corresponds to the modern pathological findings of a generally 
distributed myelitis accompanied by punctate hemorrhages 
as well as by more serious lesions through extensive areas in the 
cord and pons and an accompanying meningitis. 

Given the paralysis of one muscle or muscular group it can- 

1 "Am. Jour. Med. Sci.," July, 1914. 

2 R. W. Lovett: " The Treatment of Infantile Paralysis," " Jour. A. M. A.," 
June 26, 1915. 



IO TREATMENT OE INFANTILE PARALYSIS 

not be inferred that any other muscle or muscular group is 
necessarily paralyzed or not paralyzed in connection with it 
and no inferences can be drawn. One fact, however, is clear 
from 13,000 muscular observations made on 177 patients by 
the muscle test to be spoken of later, namely, that the paralysis 
is generally more widely distributed than would be supposed 
from a casual examination. Paralysis of the gastrocnemius 
muscle, e.g., is frequently spoken of as a clinical condition but 
really paralysis of this muscle alone occurred only twice in 
177 cases carefully measured, other muscles being weakened 
also. When one leg is involved it is common to find weakening 
of some of the muscles of the other leg. When both legs are 
affected it is not uncommon to find some weakening of some 
of the arm muscles. This fact is of great importance in formu- 
lating treatment. In thirty-two cases of the Vermont series 
taken consecutively from the files for this analysis the follow- 
ing data were observed: Ten cases had been classed by manual 
examination as having only one leg affected; by the muscle 
test nine of these showed weakness of muscle groups in the 
other leg. In eighteen other cases of paralysis of more than 
one limb examination showed unsuspected involvement else- 
where in ten (55 per cent.). 

Deformities develop during the disease in certain cases and 
will be discussed under three heads later on: (1) the prevention 
of deformity, page 35; (2) the causes and varieties of deformity, 
page 53; (3) the mechanical and operative correction of 
deformity, page 75. 

Later on the reflexes are diminished or absent in affected 
muscles, and the reaction of degeneration is present to the 
electrical current in paralyzed muscles. Sensation is ordinarily 
stated to be unimpaired but the modern pathology makes this 
seem unlikely because the posterior root ganglion is generally 
the first part of the nervous system to be affected and because 
tenderness is generally present early. In a few cases of infantile 
paralysis, old and recent, tested by Prof. E. G. Martin 1 of the 

1 Martin, Porter and Nice: "The Sensory Threshold for Faradic Stimulation 
in Man," "Psychological Review," xx, 1913, p. 194. 

Martin, Paul, and Welles: "A Comparison of Reflex Thresholds with Sen- 
sory Thresholds," "Am. Jour, of Psychology," xxvi, 19 15, 428. 



ABORTIVE TYPE 



II 



Harvard Medical School by his delicate electrical test for sen- 
sation, all showed a diminution of sensation over the affected 
limb. No more definite statement can be made at present be- 
yond the one that sensation is probably affected if one examines 
with a sufficiently delicate test. 

Disturbances of circulation occur in the severer cases accom- 
panied by atrophy of bone and muscle and by retarded growth, 
the whole group being spoken of as trophic disturbances. 
During cold weather such limbs 
become cold and blue and sub- 
cutaneous areas of discolored tis- 
sue often occur which may break 
down and if they become infected 
cause indolent ulcers which repair 
slowly. 

Abortive Type. — The abortive 
type may next be taken up as 
second in importance. This type 
was originally described by Dr. 
C. S. Caverly 1 of Rutland, Ver- 
mont, as follows: 

"It will be seen by these tables that 
six of these cases had no paralysis, as 
stated, but all of these had distinct 
rigidity of the spinal muscles, strabis- 
mus, or other symptoms referable to 
the nervous system, and are therefore 
included in this report." 

Later this type was more fully described by Wickman. 2 It 
consists of an acute febrile attack not generally to be differen- 
tiated at the outset from the attacks followed by paralysis. 

In general, abortive cases may be divided by their symptoms 
into the following types: (i) General infection, (2) symptoms 
of meningeal irritation, (3) cases with much pain like influenza, 
and (4) cases with marked digestive disturbance. The char- 
Dec. 1, 1894. 




Fig. 1. — Trophic ulcer of the 
skin in a totally paralyzed leg. 
Occurring in cold weather. 



1 New York Med. Rec 
"Jour. A. M. A.," Jan. 4, 1896. 

2 Wickman: "Die Akute Poliomyelitis, Heine Medinsche Krankheit, 
1911. 



Berlin, 



12 TREATMENT OF INFANTILE PARALYSIS 

acteristic of the abortive cases is, however, that they are not 
followed by a frank paralysis. Some of them show a suspicious 
weakness during convalescence, but to our previous methods of 
examination no paralysis has been evident. 1 That many such 
cases would more often show a real local muscular weakening 
to a delicate quantitative examination of muscular power is the 
belief of the writer and some of his colleagues, and is supported 
by a case of apparently purely abortive paralysis examined with 
great care in Vermont, where gluteal weakness previously 
unsuspected was found. In a brother of this child, however, 
examination of the same sort made the second case appear 
purely abortive, as nothing abnormal was found a few months 
after the attack. 

In such cases an immunity test may be made, where the 
diagnosis is of especial importance, by a lumbar puncture and 
the administration to a monkey of a dose of the virus mixed 
with the child's serum, in order to see if the child's serum gives 
immunity to the monkey against infection. If it gives such 
immunity the affection was clearly infantile paralysis. If it 
does not give immunity the child may or may not have had the 
disease. 

It is undisputed that cases occur which are undoubtedly infec- 
tions of this abortive type, that they are very common during 
epidemics, and that they are frequently unrecognized. Wick- 
man found 25 to 56 per cent, of abortive cases in the total 
incidence of the disease, which figure he considered far too low, 
and he was supported in this opinion by Muller, who believes 
that the abortive cases would outnumber the cases of frank 
paralysis. 2 

According to Wickman's classification six other types remain. 
These may be summarized briefly from his point of view as 
follows : 

Progressive Type. — In this type the paralysis usually 
appears first in the legs, and gradually extends upward. In 
rare instances it appears first in the arms, extends downward 

X E. A. Sharp: "Abortive Forms and Pre-paralytic Stage of Acute Poliomye- 
litis," "jour. Nervous and Mental Dis.," May, 1913. 

2 E. Muller: "Die Spinale Kinderlahmung," Berlin, 1910. 



TYPES 13 

and finally upward to the muscles supplied by the medulla. 
It is probable that the great majority of the cases that have 
in the past been described under the term of "Landry's 
paralysis" really were examples of this type of infantile 
paralysis. When the paralysis reaches the external muscles 
of respiration, as it very often does, death is likely and usually 
occurs on the fourth or fifth day. The diaphragm is also 
sometimes involved. This form must not be confused with 
that in which death results from respiratory paralysis due to 
involvement of the centers of respiration in the medulla. 

Bulbar Type. — Cases of this type have in the past been 
usually designated as polio-encephalitis superior or inferior, 
according to which of the cranial nerve nuclei were involved. 
The nuclei may be affected singly or in all possible combina- 
tions. The symptoms depend, of course, on the nuclei involved. 
The facial and abducens nerves are perhaps the most often 
affected. There may be paralysis of deglutition and of the 
muscles of the larynx. When the vagus is involved there are 
disturbances of respiration and of the cardiac action. In such 
instances, the respiration is often of the Cheyne-Stokes type 
and the prognosis is practically hopeless. Involvement of one 
or more of the cranial nerve nuclei is not very uncommon in 
connection with the ordinary spinal type of infantile paralysis. 
When this happens the resulting picture is a combination of 
the two types. 

Acute Encephalitic Type. — This type was described by 
Strumpell many years ago under the term, "acute encephalitis 
of children," but it has only recently been recognized as a 
variety of the disease under consideration. The symptoms 
resemble those of acute meningitis, the deep reflexes are, as a 
rule, exaggerated and the paralysis is spastic. The diagnosis 
is usually impossible without lumbar puncture. The prognosis 
as to life is better than it would appear and that as to recovery 
from the paralysis much better than in paralysis due to other 
cerebral diseases. 

The Ataxic Type. — Ataxia is a prominent symptom in a 
certain number of cases. In a few, it is the only nervous 
symptom; in others, it is associated with paralysis of the 



14 TREATMENT OF INFANTILE PARALYSIS 

cranial nerves and sometimes with a small amount of spinal 
paralysis. The ataxia is often distinctly of the cerebellar type. 

The Meningitic Type. — Symptoms of meningeal irritation 
are not at all uncommon in the early stages of all types of 
infantile paralysis. These are so marked in many instances 
that they present the typical picture of meningitis. Headache, 
rigidity of the neck and back, vomiting, tonic and clonic spasms, 
strabismus, Kernig's sign, delirium, coma and other signs of 
meningeal irritation may be present in any and all combinations. 
In such cases the diagnosis on the symptomatology alone is 
impossible before the appearance of the flaccid paralysis. Even 
then it is open to doubt, because flaccid paralysis may occur 
in meningitis, especially of the tuberculous type. 

The Polyneuritic Type. — Pain is an especially prominent 
symptom in some instances. It is sometimes located in the 
joints, but is more often along nerve-trunks or indefinite in its 
distribution. It is usually most marked in the paralyzed parts. 
The pain and tenderness are sometimes marked enough to 
cause the paralysis to be entirely overlooked and a diagnosis of 
rheumatism or scurvy to be made. 

The extremities are often held rigidly and all motion as 
vigorously resisted as possible, because of the pain caused 
This combination of rigidity and resistance is possible, of course, 
only when the muscles are partially paralyzed or when some 
of them are intact. The failure to appreciate the significance 
of this combination of flaccidity and spasticity not infrequently 
leads to errors in diagnosis during the acute stage. 

MORTALITY 

The death-rate was about seven or eight per hundred as the 
disease existed in Massachusetts, but no foreign statistics show 
as low a figure as this, being from 10 to 22 per cent. It must be 
remembered, however, that the death-rate will depend on the 
thoroughness with which cases are reported, and in Massa- 
chusetts there is reason to believe that the reporting of cases 
was unusually thorough. In persons older than ten, the 
mortality-rate is higher than between one and ten, and under 
one year the disease seems more fatal. 



MORTALITY 



15 



The mortality table is interesting as showing the difference 
between the foreign and American death-rate. 

Comparison of Foreign and American Death-rate 



Year 



Cases 



Death 



Mortality, 
Per Cent. 



Caverly, Vermont 

Wickman, Sweden 

Leegaard, Norway 

Zappert, Austria 

Lindner and Mally, Austria 

Furntrat, Steiermark 

Krause, Germany 

Muller, Germany 

Peiper, Germany 

Eichelberg, Germany 

Massachusetts, U. S. A 

Vermont 



1907- 



1S94 
1905 
1905 
1908 
1908 
1908 
1909 
1909 
1909 
1909 
-1910 
1914 



132 
868 

577 
266 

7i 
433 
633 
100 

5i 

34 

i,599 

235 



18 

145 

84 

29 

16 

57 

78 

16 

6 

7 

125 

50 



14-5 

16.7 

14-5 
10.8 
22.5 

13- 1 
12.3 
16.0 

11. 7 
20.6 

7-9 
17.0 



The mortality of cases in older children and in adults is 
higher than in other classes. 

Table Showing Higher Mortality in the More Advanced Ages 

. , Mortality, 

A S e ' Per Cent. 

Wickman 12 to 32 27.6 

Leegaard 15 to 30 25.8 

Furntrat Over 15 25 . 5 

Lindner and Mally Over 11 50 .0 

Massachusetts, 1910 Over 10 20.0 



DIAGNOSIS. 

The diagnosis of infantile paralysis is rarely made before the 
appearance of the paralysis, and a surprisingly large number of 
cases are wrongly diagnosticated at this early period even 
when seen in the midst of an epidemic. The appearance 
of symptoms suggesting an acute infection in a young child 
in late summer especially in a region where the disease prevails 
is always suspicious. Particularly, is this the case if accom- 
panied by sweating, nervous irritability and especially hyper- 
esthesia. Under these circumstances an immediate lumbar 
puncture is warranted and forms our chief diagnostic support 



1 6 TREATMENT OF INFANTILE PARALYSIS 

at this time. The characteristics of the spinal fluid in this 
disease are as follows: 

The fluid in the acute stage as a rule is clear and colorless and 
does not show great increase of pressure. In the first few days 
after the onset of symptoms it shows changes in the number of 
cells present or in the globulin content or in both in the majority 
of cases. The increase in cells is highest during the first week 
as a rule, and in a case of Fraser's 1 reached the figure of 1,221 
per cubic millimeter. The number of cells diminishes rapidly, 
and in Fraser's cases was above normal in only 32 per cent, in 
the third week. The globulin reaction, however, is usually most 
marked during the third week, persisting as a rule into the 
fourth week, and it may be present for a longer period. The 
increase in cells is due almost invariably to mononuclear cells 
of various types, of which the lymphocytic is the most common. 
A high polymorphonuclear count was noticed in the very 
early stages. All the fluids reduced Fehling's solution. The 
spinal fluid examination may be of value in diagnosis not only 
in the pre-paralytic stages but in abortive cases. 

The characteristics of the cerebro-spinal fluid in meningococcal, 
influenzal, and pneumococcic meningitis are so different from 
those in infantile paralysis that confusion with these condi- 
tions would hardly occur. Tuberculous meningitis, however, is 
more difficult to diagnosticate because the characteristics of 
the spinal fluid are much alike in the two conditions. In the 
former as a rule there are more cells but not always. There 
is generally more pressure in the spinal canal and the tubercle 
bacilli may be found in the fluid. 

In the early stages the blood count shows a mild leucocytosis 
with a decided increase in the lymphocytes and a decrease in 
the polymorphonuclear leucocytes. 2 

The attack itself, apart from these characteristics, may 
resemble an ordinary gastro-intestinal attack, a common cold, 
influenza, the beginning of one of the exanthemata or other of the 
common acute affections of childhood. The appearance of 

1 Fraser: "Study of the Cerebro-Spinal Fluid in Acute Polyomyelitis," "jour, 
of Exp. Med.," 1913, p. 242. 

2 Skoog: "Treatment of Acute Anterior Polyomyelitis," "jour. A. M. A.," 
Nov. 19, 1910. 



DIAGNOSIS 



17 



tenderness often marks the condition and leads to incorrect 
diagnosis; it must be remembered that tenderness is a routine 
symptom in the majority of cases. 

When the paralysis has occurred, the diagnosis as a rule 
presents but little difficulty. It is a motor paralysis, or weaken- 
ing, of erratic distribution, most marked in the legs. Reflexes, 
are diminished or lost, the reaction of degeneration is present 
in the most severely paralyzed muscles, atrophy, retarded 
growth, coldness, and sluggish circulation supervene in the later 
stages in many cases. Atrophy 
of the thenar eminence is a fre- 
quent occurrence in infantile 
paralysis and at times throws 
light on the diagnosis of doubt- 
ful cases. 

But even when paralysis is 
developed the diagnosis is not 
always quite easy. 

The difficulties occasionally 
attending the diagnosis of the 
affection may be illustrated by 
some personal cases. A boy 
with a fractured elbow, while 
the arm was in the splint, was 
seized with an attack of fever, 
and had increased pain in the 
elbow. When the splint was removed, the arm was found 
entirely paralyzed from the shoulder down, and on examination 
was found to be a typical case of infantile paralysis. A boy with 
a congenital deformity of the foot, a talipes equinus, came to the 
clinic with a history of having always been lame, but after a 
feverish attack being much lamer. Analysis of the case 
showed a mixture of congenital deformity and recent infantile 
paralysis. In one family two children of about the same age 
were brought, one with a typical cerebral hemiplegia of three 
years' duration, the other one with a typical infantile paralysis 
of an arm and a leg. The family had classed them both as the 
same condition. Two cases seen at the Children's Hospital 




Fig. 2. — Atrophy of the thenar 
eminence. 



i8 



TREATMENT OE INFANTILE PARALYSIS 



may be mentioned, one of a child with a congenital dislocation 
of the hip in one leg and infantile paralysis in the other, and 
another child with an obstetric paralysis of the arm on the right 
side existing from birth, and a subsequent infantile paralysis 
of the leg on the same side. 

PROGNOSIS 

The prognosis as to life, is expressed in the mortality table 
just given. From the age of ten upward the patient is more 
likely to die in the acute attack. Epidemics in some localities 
show great virulence. Death when it occurs in the acute 
attack generally occurs from involvement of the muscles or 
centers of respiration and is most common on the fourth or 
fifth day and is unlikely after the seventh day. Cases with 
paralysis of the upper extremity are more likely to die of 
respiratory involvement than cases with paralysis only of the 
lower extremities. 

Paralysis of the intercostal muscles is not necessarily fatal 
although if recovered from, as a rule predisposing to attacks of 
bronchopneumonia later, but perfectly good health with free- 
dom from respiratory troubles has been seen by the writer many 
years after the attack in patients who had no measurable chest 
expansion in attempted inspiration. 

The prognosis as to function is a very practical matter and 
one on which the surgeon will be closely cross-examined by 
the parents and in the present state of our knowledge the man 
of experience will, in the early days of the disease, express him- 
self with great reserve in this matter. In the acute stage it is 
particularly unwise to express a definite opinion as to the final 
function. On the whole, a severe onset is more unfavorable 
than a mild onset. The following figures were collected by 
Lovett and Lucas. 1 







Character of Final Paralysis 


Character of Onset 


Severe 


Moderate 


Mild 


Severe , 

Moderate 

Slight 


98 
84 
31 


Si 

25 

2 


28 

44 
10 


19 
15 
19 



Lovett and Lucas: "jour. A. M. A.," Nov. 14, 1908. 



PROGNOSIS 19 

But in individual instances a severe onset may be followed 
by complete recovery or mild paralysis, and a very mild attack 
by severe and extensive paralysis. 

In the acute attack, therefore, one must remember that on 
the whole, a mild onset is more favorable as to ultimate func- 
tion than a severe one but that any statement beyond this as 
to ultimate function is unsafe unless the attack be extremely 
slight in which case the outlook is more favorable. In all 
cases, however, after the onset a period of spontaneous im- 
provement may be predicted beginning with or slightly before 
the disappearance of the tenderness and progressing to any 
point up to complete functional recovery. 

This spontaneous improvement was formerly supposed to last 
for some six months but the Vermont study has shown that 
it continues much longer than this. In one case of four years 
duration 70 per cent, of improvement occurred in two months 
in muscles not being treated and 470 per cent, in the muscles 
treated by muscle training. 

In the same study, seven cases had received no treatment 
at the end of one year and at this time in thirty-seven muscle 
groups tested twice in two months there was gain in nineteen 
groups and none in eighteen, a ratio of 1 to 1 of purely spon- 
taneous improvement at the end of a year. We have as yet 
no figures to show how late purely spontaneous improvement 
lasts. Apparently the treatment of some of the affected 
muscles increases the spontaneous improvement in other af- 
fected muscles in the same individual which are not treated. 1 

As to complete junctional recovery, it occurs much oftener 
than was formerly supposed. In 191 1 an investigation was 
made of the condition of the cases in Massachusetts paralyzed 
in 1907. 2 This investigation was made by a competent ortho- 
pedic surgeon for the Massachusetts State Board of Health. 
Of the 234 cases paralyzed in that year twenty-two had dis- 
appeared, leaving 212 where the outcome was known. Of 
these cases fifty-seven were reported as having wholly re- 

1 Lovett and Martin: "Certain Aspects of Infantile Paralysis," "jour. A. 
M. A.," Mar. 4, 1916. 

2 B. E. Wood: "Boston Med. and Surg. Jour.," Oct. 5, 1911. 



20 TREATMENT OF INFANTILE PARALYSIS 

covered (27 per cent.). These cases were not all personally 
seen but still the fact remains that all of them had made 
sufficiently good progress to be considered by the parents as 
cured. In some, function seemed normal but atrophy per- 
sisted, in others there was no atrophy. The following table 
deals with the matter: 

Per Cent. 

Complete recovery without atrophy 16 28. 1 

Functional recovery with atrophy 21 36.8 

Recovery with some hypertrophy 3 5.3 

Recovery, presence or absence of atrophy unknown. 17 29.8 

Leaving out the last group, and averaging those in which the 
presence or absence of atrophy is known, shows that for every 
four functional recoveries without atrophy there were five with 
atrophy. When atrophy was present the maximum amount 
noted was as follows: 

Inches 

Calf i% 

Thigh i)i 

Arm y 2 

Forearm % 

The severity of the attack in the recovered cases was classed 
as: 

Per Cent. 

Severe 14 24.5 

Moderate 9 15.9 

Mild 28 49 . 1 

Not noted 6 

Total 57 

The time of recovery was as follows : 

One week or less 2 

One week to one month 8 

One to two months.. 8 

Two to three months 5 

Three to six months 10 

Six to twelve months 9 

One to two years 5 

Two to three years 5 

No data 5 

Total 57 



PROGNOSIS 



21 



Through the first weeks after the onset the severest cases 
show but little return of power, tenderness is severe and lasts 
a long time, and the paralysis is widespread. In cases in which 
at the end of two months there has been but little gain, the 
outlook is not encouraging for very good function. P? 

The question of prognosis arises most acutely in the sta- 
tionary period in connection with treatment. The question 
of spontaneous improvement has been discussed and there 





Fig. 3. — Outward rotation 
of right leg; quadriceps 
paralysis. 



Fig. 4. — Talipes equinus of right foot and 
quadriceps paralysis of the right leg. The 
former locks the knee in extension when 
weight is borne upon the leg and makes it 
possible for the patient to walk without 
support. 



remains the question of improvement under treatment. In a 
general way the outlook is better in the first year than later and 
the more voluntary power shown by the affected muscles the 
better the outlook for such muscles. It must be remembered that 
total paralysis is less common than partial and that the problem 
of strengthening weakened muscles by therapeutic exercises 
has made great strides in late years. Most untreated cases 
or badly treated cases are capable of marked or great improve- 
ment by treatment. The writer has never seen more than 



2 2 TREATMENT OF INFANTILE PARALYSIS 

two or three cases that could not be made to walk in some form 
or other and these cases were of the severest possible type — 
a really bedridden case of infantile paralysis should almost never 
occur. Deformities may have to be removed, and apparatus 
furnished to trunk and legs but locomotion is practically always 





Fig. 5. Fig. 6. 

Fig. 5. — Gait in severe double paralysis of the quadriceps muscles. The 
patient presses back on both knees and bends forward to prevent knees from 
flexing. 

Fig. 6. — Method of walking with a paralyzed right quadriceps. The knee is 
prevented from flexion by the pressure of the hand. 

possible. There seems to be no time limit to the benefit to be 
derived from treatment, a case of the writer's of twenty-five 
years' standing who had never walked with the feet on the 
ground being most satisfactorily treated by braces which 
enabled her to walk with a cane. 

With regard to the disability caused by various locations 
of the paralysis, the following facts may be borne in mind. A 



PROGNOSIS 23 

complete paralysis below the knee with the thigh and hip 
muscles fairly sound, allows walking, but the foot is lifted high 
and the gait is awkward. Paralysis of the quadriceps whether 
the foot is paralyzed or not makes it impossible to bear weight 
on the leg without a brace or assistance from the hand unless 
(1) there is an equinus deformity in the foot, or (2) the knee 
becomes hyperextended, or (3) the patient learns to walk 
with the leg outwardly rotated, or (4) the patient learns to 
walk leaning forward at the waist, or (5) if with a weakened 
quadriceps the hamstring muscles remain strong. Paralysis 
of one gluteal muscle with the rest of the leg fairly sound 
causes a bad limp. The paralysis of both gluteals in con- 
nection with leg paralysis makes walking difficult and the 
asset of fairly good hip flexors and gluteals in a patient with 
paralysis of both legs may make the difference between being 
always dependent on crutches or walking without them. These 
statements, however, must be regarded as being only of the 
most general sort because the interdependence of muscles is 
such that no muscle acts singly and alone, but these state- 
ments roughly cover the requirements of standing and walking 
unaided, a most important question in formulating a functional 
prognosis. 

Prognosis as to shortening will frequently be expected from 
the surgeon. It must be remembered that the amount of leg 
shortening except from dislocation of the hip is rarely great 
and an ultimate shortening of two inches would be exceptional ; 
at times somewhat more than this occurs but it is rare. The 
important fact to remember in this aspect of the prognosis is 
that the amount of shortening is not necessarily proportionate 
to the degree of the paralysis, slight cases often being accom- 
panied by much shortening and severe cases by moderate 
shortening. The shortening is due to the fact that the leg 
grows more slowly than the other and this retardation of growth 
is accounted for by the supposition that the so-called trophic 
centers of the cord are more affected in some cases than in 
others. There is nothing to show that the use of a brace 
seriously promotes shortening. On the one hand, the brace 
constricts the limb and restricts the activity of certain muscles 



24 TREATMENT OF INFANTILE PARALYSIS 

but as a brace is put on to allow walking and thus to promote 
function of the whole limb it cannot be assumed that its use 
would under these circumstances retard the growth of the leg, 
when it is remembered that without the brace the limb probably 
would not be used at all. 

Effect of Treatment on the Prognosis. 1 — In the Vermont 
series of cases the chance of improvement under treatment 
by muscle training and restriction of exercise at the end of 
one year after the onset was found to be as follows: In a 
two months' period by means of the muscle test the chance of 
improvement in affected but not totally paralyzed muscles 
under expert daily treatment was 6 to - 1 ; under supervised 
home exercises 3.5 to 1; with home exercises without super- 
vision 2.8 to 1; while untreated affected muscles in these 
patients showed an improvement ratio of 1.9 to 1. Moreover, 
the outlook for muscles totally paralyzed at the end of one year 
seems better than supposed. Of forty-four totally paralyzed 
muscle groups in the Vermont series twenty-one (48 per cent.) 
developed demonstrable power at the end of two months, 
while in forty-four totally paralyzed muscular groups not 
receiving treatment, twelve (27 per cent.) developed demon- 
strable power in the same period. 

As a concrete instance of the prognosis in a definite group 
of cases seen at a six months' interval who had received treat- 
ment by muscle training a quotation from an article 2 may be 
given bearing on cases seen by the writer in Burlington, Vt., 
in January, 191 5 and July, 19 15. 

" Twenty-four cases: one had received no treatment and 
was no better, one was too unruly to examine and one was too 
young for accurate data. In the remaining twenty-one cases 
the improvement had been from slight to very great. The 
cases were all affected in the summer of 19 14. The following 
changes were noted in muscles: (see page 25). 

"The two most striking cases in the Vermont series were to 
be found in the Burlington group. A man of thirty-eight, at- 

^ovett and Martin: "jour. A. M. A.," Mar. 4, 1916. 
2 Lovett and Martin: "Vermont Medicine," February, 1916. 






PROGNOSIS 25 

Partial Paralysis Total to Partial 

to Recovery Paralysis 

Deltoid 6 1 

Pertoral 3 o 

Trapezius 3 1 

Triceps 1 o 

Arm muscles 2 o 

Forearm muscles 1 o 

Bath muscles 5 o 

Abdominal muscles 5 1 

Quadriceps 1 2 

Hamstrings 2 o 

Gastrocnemius 4 o 

tacked in August, 1914, was helpless and brought to the 

January clinic on a stretcher, and was with one exception the 




Fig. 7. — Method of progression in a boy unable to walk, untreated. By treat- 
ment later enabled to walk with braces. 



severest case seen in 
living by selling farm 
help him in and out. 
ance also on one side, 
successful fishing trip 
" A girl of eighteen, 
walk alone. In July 



Vermont. In July he was earning his 

machinery in his wagon, taking a boy to 
He walked with one crutch with assist- 
he was able to fish, and had been on a 

during the summer. 

affected in 19 14, in January could barely 
she walked with a slight limp. Eight 



26 



TREATMENT OF INFANTILE PARALYSIS 



important muscles had recovered under persistent exercise, and 
the improvement began a few days after starting on exercises, 
previous to which the patient's progress had been stationary." 
The table given in the section on symptoms is of value in 
prognosis as there is given in it the proportion of partial to total 
paralysis. Other facts have been mentioned in the same 
section suggesting the frequency of total paralysis below the 




Fig. 



8. — Mode of progression in a child with contraction deformity of hip and 
knees, untreated. The body is lifted along by the hands. 



knee (82 per cent, of all cases) and the frequency of severe 
paralysis in the shoulder. 

In muscles which remain totally paralyzed to attempts at 
voluntary contraction at the end of three months the outlook 
for the recovery of any marked degree of function is not good 
but neither is the situation hopeless. 

The modern prognosis, therefore, is wholly different from the 
old prognosis. In 1886, Gibney, 1 already an authority in ortho- 
pedic surgery, wrote: "He must be a bold optimist in thera- 
peutics who can see in any drug, in any agent, in any appliance 

1 V. P. Gibney: "New York Med. Jour.," Apr. 3, 1886. 



PROGNOSIS 



27 



a power which will restore the muscles whose nerve supply 
comes from these once living ganglion cells. ... In other 
words all our skill is directed toward limiting the paralysis 
and correcting or preventing the deformity which so frequently 
follows." Today one would say that the modern early care 
perhaps limited the paralysis by omitting meddlesome thera- 
peutics, that we had learned that most deformities could be 
prevented, that we recognized the fact that the great majority 
of muscles were weakened rather than paralyzed and that we 
had learned that impulses might often be sent from the brain 




Fig. 9. — Quadruped progression in a severely paralyzed child. Never treated. 

around the destroyed centers by new paths to the muscle 
and that this was best accomplished by muscle training, 
and finally that skillful muscle training and the proper care of 
weakened muscles were of the greatest importance in in- 
fluencing the ultimate degree of function. We should no 
longer be content to put on a brace and let the child get about 
as best he can. This, from today's point of view, would be 
the crudest of treatment. 

Two classes of cases are probably not much affected by treat- 
ment: first, those where the affection is so severe that it 
has left behind an extensive flaccid paralysis; and second, 
those which are so slight that they are going to recover any- 
way. In the opinion of the writer in practically all other early 
cases the matter of precise, effective and intelligent treatment 



28 TREATMENT OF INFANTILE PARALYSIS 

has great effect upon the prognosis as to ultimate function — 
and it must be further remembered that all cases must undergo 
a period where they must either have non-operative treatment 
or no treatment at all. Because all experienced men all agree 
that operative treatment is not to be undertaken till two years 
after the onset and this leaves a space of two valuable years 
when the case may be treated in the best way or loosely treated 
or neglected. 

Prognosis after Operation. — It would be unfair to judge the 
post-operative results to be obtained to-day by the literature 
of a few years ago. Modern operating has become much more 
simple, much more definite and much more effective. With 
this increased efficiency has come a much larger number of 
operations and the prospect of improving function in cases 
formerly irremediable. The question of acetonuria in operating 
on children with infantile paralysis must not be forgotten for 
in the writer's experience this class of children seem more 
likely to acquire post-operative acetonuria than in others. 
The operations are rarely attended by any appreciable 
risk to life and the tissue heal as readily as do sound ones. 
When fractures occur, they heal normally. 



CHAPTER II 
TREATMENT 

THE ACUTE PHASE— SERUM AND DRUGS— REST— QUARANTINE 
—PREVENTION OF DEFORMITY— SUMMARY OF TREATMENT 

The treatment may be divided, for purposes of discussion, 
into three phases. 

I. The acute phase — from the onset to the disappearance of 
the tenderness. 

II. The convalescent phase — beginning at the end of the 
acute phase and continuing so long as spontaneous improve- 
ment (about two years) is marked. 

III. The chronic phase — when the affection has become 
more stationary and deformities if present have become 
established. 

These phases or stages appear to be as well marked as are 
those of most affections thus subdivided, but at times they 
run into each other and are often imperfectly separated. 
They are used in this instance merely to simplify description by 
subdividing the subject. 

Plan of Treatment. — A general plan of treatment may be 
formulated which may make clearer the detailed description 
which comes later. In the acute phase our efforts are confined 
chiefly to limiting the destructive process. In the convalescent 
phase which will carry us practically two years from the onset 
there is no question of any operation (except minor tenotomies) 
and our efforts are concerned with the restoration of muscular 
power and the prevention of deformity. This is the time in 
the writer's experience where the greatest gain is to be made 
in the matter of ultimate function and, because all cases will 
in any event be non-operative during this period, much 
stress must be laid on it for this reason. The considerations 
governing its management are as follows : Many muscles are 
weakened and some are wholly paralyzed because of injury to 
certain nerve centers. Weakened muscles may be strength- 

29 



30 TREATMENT OF INFANTILE PARALYSIS 

ened by muscular exercise and in addition to this, impulses 
sent from the brain to the muscle may be trained to find new 
paths. This is because the communications between the 
nerve centers and the connections between the nerve centers 
and muscles are very extensive and intricate and because most 
often not all the centers controlling one muscle are wiped out. 
As a result of this, muscle training in this period is physio- 
logically sound and practically of great value and reinforces 
and establishes the normal spontaneous improvement. For 
this reason it has been considered in detail. Moreover, fatigue 
must be avoided and normal ambulatory conditions restored 
so far as possible by apparatus. 

At the end of about two years the chronic period may be 
assumed to have begun and here the treatment is more largely 
operative although the conditions of the convalescent period 
still hold to a less extent. 

THE ACUTE PHASE 

This phase may be regarded as beginning with the beginning 
of the onset and lasting until the tenderness of the affected 
limbs has practically disappeared. In 604 cases in the Massa- 
chusetts series analyzed by Lovett and Richardson the time 
of disappearance of pain and tenderness was as follows: 

Cases 

One day or less n 

Two days 22 

Three days 29 

Four days 15 

Five days 14 

Six days 3 

A few days 28 

One week 59 

One to two weeks 91 

Two to three weeks 46 

Three to four weeks 33 

Four to five weeks 1 

Six to seven weeks 1 

One to two months 28 

Two to three months 5 

Several months 3 

Until death 39 

Present when report was made . 175 



Per C 


lent. 


1 


.8 


3 


.6 


4 


.8 


2 


•5 


2 


•3 





■5 


4 


.6 


9 


•7 


15 


. 1 


7 


.6 


5 


■4 





. 2- 





. 2 


4 


.6 





.8 





5 


6 


•5 


29 


.0 



ACUTE PHASE 3 I 

We have no knowledge at present of any drug or serum or 
means of treatment which will protect from infection, abort 
the attack, or prevent the paralysis. Even if we make the 
diagnosis in the pre-paralytic stage it must be remembered 
that practically we are no better off than without it, so far 
as preventing the paralysis is concerned. Netter 1 of Paris 
has advocated the injection into the spinal canal of blood 
serum from recovered persons and reports thirty-two cases 
in which he believes the paralysis has been modified by the 
treatment, but the matter is still in the purely experimental 
stage and has not yet received general confirmation although 
reported by one other set of observers. 2 

Since it was shown by Cushing and Crowe that hexamethy- 
lenamine (urotropin) is in part eliminated into the intradural 
space it has seemed possible that it might be of value in early 
infantile paralysis and it has been extensively used in the 
treatment of the acute stage of the disease and in prophylaxis. 
The experimental evidence for its use is as follows: 3 "when a 
large dose of the drug is administered by mouth, its presence 
can be detected by chemical tests in the cerebro-spinal fluid 
soon afterwards. We have ascertained that when the virus 
of poliomyelitis is injected intracerebrally in monkeys in which 
the hexamethylenamine is already present in the fluid, and 
the drug is then administered by mouth daily thereafter, that 
in a proportion of animals so treated, but not in all, first, the 
incubation period of the disease is prolonged (from six to eight 
days to twenty-four days) and next the onset of the paralysis 
is entirely prevented. When the drug is administered by mouth 
and the immune monkey serum by injection into the subdural 
space, the paralysis can also be prevented and possibly with 
greater certainty." There is no experimental evidence that 
the drug is of any value when infection has occurred. 

On this evidence the use of hexamethylenamine seems 
warranted and legitimate as a prophylactic when such is 
desirable. In the early stages of the disease it is extensively 

1 Netter: "Bull de l'Acad de Med.," Oct. 12, 1915. 

2 Alfaro and Hitce: "Summa Medica, Buenos Aires," Aug. 5, 1015. 

3 Flexner and Clark: "jour. A. M. A.," Feb. 25, 1911, p. 585. 



32 TREATMENT OF INFANTILE PARALYSIS 

used especially in the pre-paralytic stage and at times it appears 
to be useful but there is no evidence in any individual case that 
can be relied on to prove that it has been of any value. Still 
in the absence of any remedy of proved value its use seems 
legitimate in the early stages, on general grounds, on experi- 
mental evidence, and because used with care it is harmless. 

Rest in bed at this stage is strictly to be enforced in all 
cases. 1 In the moderate and severe grades of the affection the 
patients are too ill to be elsewhere than in bed, but in the 
slighter cases it is well to remember that the pathological 
condition is a hemorrhagic myelitis and that function of the 
affected members means function of their motor nerve cells 
and that such function is probably harmful on general prin- 
ciples. In all grades of the affection it is obviously indicated to 
secure the maximum degree of rest and quiet even where it is 
not necessitated by general prostration, pain and tenderness. 

A German writer 2 has advocated the application of a jacket 
of plaster of Paris to ensure absolute quiet to the vertebral 
column but this seems hardly necessary and is not often done. 
During this stage joints will not become ankylosed, muscles 
will not become hopelessly wasted, the circulation of the affected 
members will not become seriously upset if the patient is let 
alone, whereas if the patient is not let alone and is massaged, 
manipulated, treated with electricity, etc., during this stage, 
there is a strong possibility that the recovery may be less exten- 
sive than it would otherwise have been. That massage during 
convalescence is harmful so long as the patient is tender has 
been shown in two of the writer's patients. In one, a boy of 
seven, the tenderness was slight at the end of ten weeks, and 
gentle massage of five minutes was prescribed with a view of 
hastening its disappearance. In a week this boy was so tender 
that he could not bear the weight of the bedclothes, and was 
put in plaster of Paris for a week, during which week the 
tenderness disappeared. A girl of fifteen in the fourth week of 
her disease was massaged twice daily in a general hospital, 
being given heavy massage by a person without especial train- 

1 Robert Jones: "British M. J.," May 30, 1914. 
2 Hohmann: "Munch. Med. Wchsft.," 1909, No. 49. 



ACUTE PHASE 33 

ing. Her suffering became so great that she was placed in a 
private hospital, where the tenderness persisted to a marked 
degree for two months more. 

There is absolutely no evidence to show that the use of elec- 
tricity at this stage is of any benefit or has any local effect 
either upon the organism or the affected cord. This point is 
emphasized because parents, relatives and inexperienced prac- 
titioners have heard so much of rapid recoveries under massage, 
electricity and the like that such measures are often used too 
early, to the detriment of the patient. The fact is that the 
amount of early paralysis is dependent on the amount of tissue 
really involved during the acute attack, that no two cases are 
alike, and that much of the early paralysis is due to obstruction 
of the terminal spinal arteries and anemia of the centers, which 
speedily is recovered from. It is our business to see that during 
the stage now under discussion conditions are made as favorable 
as possible for the recovery of the spinal centers, and this 
recovery is obviously to be expedited by physiological rest to the 
affected centers. 

Tenderness, which so commonly exists, is to be accepted as 
evidence of congestion and irritation of the cord, and conse- 
quently of a process still active. In cases where the tenderness 
lasts excessively long there seems no need of insisting on recum- 
bency until it disappears, but when it has become distinctly 
less, the patient may be allowed to sit up, if this can be done 
without discomfort. At this time limbs may be passively 
moved to relieve joint stiffness, and parts of the body not tender 
may be gently rubbed. There is no evidence that strychnine, 
ergot, etc., are of any use at this stage. 

At this period a warm bath is generally of benefit because 
the buoyancy of the water diminishes the weight of the limbs 
and permits motion which is not possible out of water because 
the limbs are thus supported. The addition to the bath of 
sea-salt of course increases the specific gravity of the water. 
Immersion in a bath is- not desirable during the first two or 
three weeks of the paralysis but may be used before tenderness 
has wholly gone, the patient being lifted into the bath on a 
sheet. 

3 



34 TREATMENT OF INFANTILE PARALYSIS 

A matter often lost sight of is that infantile paralysis is an 
infectious disease and that long-continued mild sepsis, loss of 
appetite and flesh may persist and should be borne in mind. 
In certain cases it may be months before the general condition 
becomes normal the general sequelae being much the same as 
they might be after one of the acute exanthemata. 

In the matter of quarantine it is generally assumed that the 
affection is transmissible, 1 that the virus probably enters by 
the respiratory tract and is apparently excreted in the secre- 
tions of the throat and nose. With regard to the length 
of time that the disease continues to be transmissible we have 
no exact information whatever, and any period set is largely 
guesswork. The rules regarding quarantine of two states are 
given as examples of the present point of view of representative 
boards of health in the matter. 

Michigan. — i. Cases must be reported to local board of health. 

2. Conspicuous placard on the house. 

3. Quarantine of household four weeks minimum. Head of family 
and other adults may be released from quarantine after antiseptic bath 
and in disinfected clothing. 

4. Complete disinfection of rooms and clothing after death or recovery 
of patient. 

Minnesota. — Immediate notification by the regular reporting post card 
or special blank provided shall be made by the attending physician (or 
other person as specified) to the local health officer in cities and villages 
and to the chairman of the board of supervisors in townships of each case 
or suspected case of anterior poliomyelitis. 

The patient shall be isolated for at least two weeks after the first 
symptoms appear. The patient's room shall be carefully screened through- 
out the course of the disease and during the convalescence if any flies or 
insects are about. 

Nose, throat, and mouth discharges must be received on cloths and 
burned at once. Bowel and bladder discharges must be disinfected 
before being deposited in a sewer or cesspool. Where no sewer or cess- 
pool exists, bowel and bladder discharges shall be disinfected and after- 
ward buried in such a manner as to prevent the access of flies or insects 
to them. All articles exposed to possible infection from the aforesaid 
discharges must be cleansed and disinfected according to the directions 
of the State board of health. 

In case of death the funeral shall be strictly private. Children in the 

1 Flexner: "jour. A. M. A.," Oct. 12, 1912. 



EARLY DEFORMITY 



35 



house, and persons associated with the patient, shall be kept under ob- 
servation for two weeks after last exposure. During this period the 
children shall not attend any public, private, parochial, church, or Sunday 
school, or any public or private gathering whatever. Residence, board- 
ing or lodging in the house during the isolation of the case shall constitute 
exposure. 

The prevention of contractions and early deformity is of 

great importance at this stage of the affection for such contrac- 





FlG. 



10. — Severe talipes equi- 
nus of right foot. 



Fig. ii. — Dropped foot from complete 
paralysis of the foot in that position simu- 
lating equinus but without hollowing of the 
sole. 



tions may occur early and are on the whole evidences of neglect 
and lack of proper surgical care. This is not the case in regard 
to scoliosis. 

These contraction deformities occur earlier than generally 
supposed and marked equinus deformity has been observed 
at the end of three weeks and noticeable scoliosis in a recum- 
bent patient in four weeks. One hundred and fifty cases of 
the 1 9 14 epidemic were seen in Vermont at from two to six 



36 TREATMENT OF INFANTILE PARALYSIS 

months after the onset. There were only sixteen cases of 
equinus deformity, this small number undoubtedly being due 
to the care taken by the doctors in the acute stage. There 
were nine cases of flexion of the knees and seven of flexion of 
one or both hips. In one case both hips were flexed and one 
knee contracted to a right angle and the other to 45 degrees. 
There were sixteen cases of scoliosis and four of hyperextension 
of the knee. These figures show how early in the affection 
serious deformity may arise. 

It may thus be seen that many cases reach the convalescent 
stage with shortened muscles due to neglect while they have 
been lying in bed. If the feet are not supported they are likely 
to drop into a position of plantar flexion, a position aggravated 
by the weight of the bedclothes, and when the patient is ready 
to be stood on his feet he may be found to have acquired an 
adaptive shortening of the gastrocnemius muscle — in other 
words, a mild talipes equinus. If this exists he cannot stand 
or walk properly with or without braces until it has been 
removed. 

To prevent this the feet should be supported at right angles 
to the legs from the outset by plaster-of-Paris splints, right- 
angled tin splints, leather splints or anything of the kind, which 
can be worn most of the time, and for the rest of the day the 
patient's feet may be supported at right angles to the legs by 
means of a soap box, resting at the foot of the bed against the 
foot board, covered with a blanket and placed under the bed- 
clothes for the feet to rest on and thus be held at a right angel 
to the legs. 

Lateral curvature of the spine sometimes begins while the 
patient is lying on his back but in a case whose back muscles 
are as severely affected as this, it seems likely that little would 
be gained by treatment begun during the recumbent period. 
There is therefore no especial treatment to be advised at this 
stage for the scoliosis, beyond the unnecessary assumption of 
attitudes aggravating the back deformity. 

In occasional cases in this tender phase it is not wise to cause 
too much discomfort to prevent contraction and sometimes it is 
wiser, to cease aggravating the patient by painful attempts of 



ACUTE PHASE 37 

* 

this sort, to allow the tenderness to disappear and then to 
remove the contractions by stretching as will be mentioned 
later (page 75). 

In a case of this sort of the writer's in a girl of fifteen, tender- 
ness has been greatly prolonged by heavy massage given early. 
When the patient came to the writer's care at the end of six 
weeks she lay with knees flexed and toes pointed and any 
other position caused great pain. Wee*ks passed with no great 
change in the tenderness and caliper splits were applied to the 
legs with a view of straightening the knees, but the pain was 
intolerable, the patient's general condition suffered, and the 
contraction became worse. Finally, all halfway attempts at 
correction were abandoned and the patient was let alone until 
tenderness had disappeared and the condition had quieted 
down which was four months after the onset. Then plasters 
were applied, cut and wedged as will be described and the legs 
straightened in three weeks without much discomfort. This 
case has been given in detail because it is a type of case oc- 
casionally seen where deformities must be allowed to occur 
in spite of careful treatment. 

SUMMARY OF THE TREATMENT OF THE ACUTE PHASE 

Rest until the tenderness has disappeared, absence of meddle- 
some therapeutics either medicinal or physical, the use of 
warm baths in the later part of this period. The prevention 
of contractions. 



CHAPTER III 
TREATMENT 

THE CONVALESCENT PHASE— AMBULATORY TREATMENT— BRACES 
—BALANCE— PREVENTION OF PERMANENT DEFORMITY 
—STAGES AND VARIETIES OF DEFORMITY— DISLOCATIONS 
—RESTORATION OF NERVE AND MUSCLE POWER— MAS- 
SAGE— HEAT— ELECTRICITY— MUSCLE TRAINING 

THE CONVALESCENT PHASE 

With the disappearance of the tenderness the acute stage 
of the process in the cord may be assumed to be at an end and 
the time to be at hand when one may make an estimate of 
the damage done and plan the campaign of treatment. This 
stage has been in this book arbitrarily assumed as beginning 
with the cessation of tenderness and ending when spontaneous 
improvement has largely ceased, i.e., when the case has become 
in large measure stationary. That the cessation of spontaneous 
improvement occurs far later than formerly supposed has 
already been mentioned and the end of this phase is difficult 
to fix although it may be arbitrarily set at about two years 
after the onset because during this time all are agreed that 
major operative procedures are not to be undertaken. 

So far as treatment is concerned the situation is as follows: 
A hemorrhagic myelitis accompanying a general infection 
has destroyed or impaired or temporarily inhibited the function 
of certain nerve centers, the muscles controlled by these centers 
have been inactive and have wasted, the circulation has become 
sluggish, and the general resistance of the patient is below par. 
But the time has come to begin the work of restoring the 
maximum function to affected muscles, and one must carefully 
consider what means will most rapidly bring this about. 

AMBULATORY TREATMENT 

It is on the whole desirable for the patient to get into the 
upright position early in the convalescent phase. The reasons 

38 



AMBULATORY TREATMENT 39 

for this are : first, that the prolongation of the recumbent period 
is unnatural and undesirable on account of its effect on the 
circulation because the circulation is stimulated and regulated 
by the normal upright attitude and undesirably affected by 
prolonged recumbency; second, because the sitting and later 
standing attitude is a stimulus to the muscles themselves and 
to the nerve centers controlling them to attempt to balance 
the body and thus incites instinctive action on the part of a 
large number of muscles, exercising in this way muscles which 
could not otherwise be reached; third, because the nervous 
system of children of the age generally attacked is as a rule 
unfavorably affected by prolonged inaction and recumbency; 
and fourth, because outdoor air and diversion are on general 
grounds desirable. 

There is, however, the danger of overusing the muscles by 
this proceeding and some writers 1 are in favor of prolonged 
disuse of affected muscles. But the old practice is too common 
of allowing patients to sit or lie around for months or years 
with no attempt to walk until many of them have developed 
serious flexion deformities. On the whole, therefore, it is the 
belief of the author that the upright position and very re- 
stricted ambulatory activity should be undertaken within two 
or three months of the onset, except in unusual cases. Fatigue, 
as will be mentioned, is carefully to be guarded against, 
especially in walking too early with muscles still weakened. 

Sitting in many cases is at first impossible on account of 
weakness of the spine and abdomen but in such cases the 
patient may be first propped up in a chair with pillows until 
he is able to sit alone. This must be determined by the 
patient's resistance. All cases should be carefully watched at 
this stage as to the presence or development of lateral curva- 
ture of the spine a condition too frequently overlooked. If 
the spine tends to curve in the sitting position the patient 
should be made to sit in a way to counteract the curve. 

Abdominal paralysis or weakness frequently occurs and is not 
infrequently overlooked and demands attention. The child 
is unable to rise from the lying to the sitting position unaided 

J Judson: "Denver Med. Times and Utah Med. Jour.," Oct. 1, 1907. 



4Q 



TREATMENT OF INFANTILE PARALYSIS 



•x^^^^^L^ 






1| 




i * ^B 



Fig. 12. — Extensive paralysis of two years' duration showing abdominal 
paralysis, scoliosis, talipes equinus on right. Paralysis of both legs. 




Fig. 13. — Muscle chart of the patient shown in Fig. 14. The normal 
muscles are not shaded; the partly paralyzed muscles are shaded with coarse 
lines. The wholly paralyzed muscles are closely shaded. 



WALKING 



41 



and in sitting the abdomen is prominent and the child sits with 
the spine flexed. If this is allowed to go uncorrected the lower 
edge of the thorax begins to flare out where it rests on the fluid 
abdominal contents and permanent bony deformity may occur. 
One-sided paralysis of the abdomen may rarely be found. In 
all cases of abdominal weakness or paralysis an abdominal 
support should be furnished by means of an accurately fitted 
cloth corset. In many cases recovery will occur under these 




Fig. 14. — Abdominal paralysis combined with extensive leg paralysis. The 
affected muscles are shown on the chart in Fig. 13. 

conditions which probably would not have occurred had the 
muscles remained unsupported and continually stretched. 



WALKING WITHOUT BRACES 

From the time when the patient is able to sit alone he may 
or may not be able to walk without apparatus. Even if he 
can, it must be remembered that affected muscles have in the 
early months after the attack, greatly impaired power and can 
be easily fatigued and that such fatigue is detrimental to their 
welfare. It must be strongly urged when the power has 
returned rapidly and early walking is possible that great care 



42 



TREATMENT OF INFANTILE PARALYSIS 



should be taken to guard against fatigue — walking at first 
being limited to only a few steps and for the first months in all 
cases being reduced to a very small amount. Fatigue may be 
noticed by a flagging in the walk or by a feeling of local or 
general tiredness. 

BRACES FOR WALKING 

In case the patient cannot stand or walk unaided, or stands 
or walks in a position of deformity as, e.g., with a knee hyper- 




Fig. 15. — Mechanics of apparatus required to prevent knee from flexing in 
paralysis of the quadriceps muscle. (Bradford and Lovett.) 

extended, the use of a brace becomes advisable, for the problem 
of getting the patient onto his feet is just as urgent as if he 
could walk unaided. A patient, however, may be extensively 
paralyzed in the leg and yet be able to get about without braces 
or assistance — and the use of a brace is not to be advised unless 
it has a definite requirement to meet. Paralysis of the leg below 
the knee for example, as has been mentioned, does not require 
the use of the brace, although apparatus sometimes diminishes 
the limp. If certain other muscles are affected, however, which 
have been mentioned in prognosis (page 22) a brace becomes 
essential for ambulatory activity. This point is emphasized 



BRACES FOR WALKING 43 

because so many children to their great detriment are allowed 
to lie or sit around for months or years after the attack with no 
attempt to encourage functional activity. This is most unde- 
sirable because it promotes muscular atrophy by disuse and 
favors deformities which are more likely to occur in a patient 
who always sits with the legs flexed and the feet hanging than 
in one going about with proper apparatus. 




Fig. i 6. — Paralyzed child strapped in a walking frame wearing splints to 
prevent forward dropping of the knee. {Boston M. and S. Jour.) 

As the quadriceps extensor femoris is of all muscles in the 
body the one most frequently paralyzed (152 in 1,452 groups) 
the splint to supplement that is of great importance in this 
connection and of all the appliances to be used in infantile 
paralysis is the one most generally necessary at the outset. 

The splint is a so-called "caliper" made of heavy iron 



44 



TREATMENT OF INFANTILE PARALYSIS 



wire one-quarter inch or more in diameter. Two pieces of this 
run up on the outside and inside of the leg, respectively, and 
are joined together at the top just below the gluteal fold by a 




Fig. 17. — Side view of "caliper" splint, with knee strap and checks in the 
heel to prevent the dropping of the heel or front of the foot as may be needed. 

(Boston M. and S. Jour.) 



posterior iron band which is curved and padded. Below at the 
level of the sole of the boot these irons are turned at a right 
angle to fit into a tube in the heel of the boot, a fenestrated 



BRACES FOR WALKING 



45 



leather knee cap passes over the front of the knee to keep it 
from flexing and a circular leather strap passes around the two 
irons below to keep them from spreading and slipping out of 
the tube in the boot. 

This apparatus is not generally in the first instance jointed 
at the knee as it is lighter without being jointed. 

Dropping of the toes is prevented when necessary by a flange 
which is fastened to the heel of the boot which strikes against 
the splint upright thus preventing the dropping of the foot but 





f-^Vv^%^~>^rVl 



o 




Fig. 18. — Fig. 19. — Thomas caliper splint. 
Jointed caliper 
splint. 



lvv M 

Fig. 20. — Drop catch 
for knee splint. (Brad- 
ford and Lovett.) 



allowing dorsal flexion. With this appliance on, the patient 
may be placed on his feet and held under the arms, or an upright 
board may be set up and the patient strapped to that by 
straps passing under the arms, thus getting used to having his 
weight come on his feet. 

With this appliance the patient's legs are converted into 
props for the trunk, but the trunk must be held erect on the 
legs by the glutei muscles before he can stand or walk unaided, 
or the deficiency of the glutei muscles must be supplied by 



46 



TREATMENT OF INFANTILE PARALYSIS 



crutches which will hold the trunk erect on the legs, thus mak- 
ing the action of the glutei less necessary for maintaining 
the upright position. Of course, these remarks apply to the 
severer cases and in the milder cases, as in the affection of the 
quadriceps of one leg, the mere application of a caliper and 
splint is enough to enable the patient to walk without further 
assistance. 

The caliper braces spoken of are later replaced by braces 




Fig. 21. — Detail of wire splint, showing adjustment to thejshoe, with check to 
prevent toe-drop. {Boston M. and S. Jour.) 



made of flat iron shaped to the leg and jointed at the knee. 
Such braces can (i) either be fastened to the boot by being 
attached by a plate to the under side of the sole, or (2) they 
may end in a plate going inside of the boot to which the foot 
may or may not need to be strapped, or (3) they may end just 
as the calipers do by being turned at a right angle to fit into a 
tube in front of the heel of the boot. 

In cases of weakness of the gastrocnemius even of the slight- 



BRACES FOR WALKING 



47 



est grade it is desirable to raise the heels of the shoes in order 
to prevent the weight of the body from coming upon and 
stretching the muscle in walking. The heels of the boots of 
young children should be half or three-fourths of an inch high 





Fig. 22. — Apparatus with ankle strap to check paralytic valgus. If the 
upright is applied to the inside with the ankle strap applied to the outside a 
varus deformity is checked. {Boston M. and S. Jour.) 

and of older children an inch to an inch and a half and the 
weight of the body should not be allowed at any time to come 
upon the foot without the boot, that is, barefoot walking even 
in undressing, sneakers, tennis shoes, etc., should be absolutely 





4^^ 



Fig. 23. — Taylor varus shoe. 



Fig. 24. — Valgus shoe. 



forbidden. In this way apparently stretching of the muscle is 
prevented, its recovery or improvement favored, and perma- 
nent talipes calcaneus avoided in many cases. 

If there is total paralysis below the knee the foot will drop 
and the gait be ungainly. This may be checked by a sole 



48 TREATMENT OF INFANTILE PARALYSIS 

plate attached to two uprights running two-thirds of the way 
to the knee and ending in a posterior calf band at this level 
(Fig. 75). Or a short caliper may be used ending below the 
knee. A stop catch at the ankle will prevent dropping of the 
foot beyond a right angle. In such cases of leg paralysis if 
the foot turns neither onto the inner nor the outer border a 
plate in the shoe or fastened to the bottom of the shoe will 
suffice. If it rolls onto either side, that is, into varus or val- 
gus positions, a sole plate such as is used in the Taylor club- 
foot shoe or the reverse of this for valgus will be required. 

Summary of Walking Apparatus. — The question of apparatus 
for the leg is rather simple. Apparatus is used to prevent 
persistent malposition or to make walking possible or to im- 
prove walking. 

Generally the defect is that the patient cannot hold the knee 
straight and a splint to do this is desirable (the caliper leg 
splint). If the glutei are involved these braces may have 
to be fastened to a leather jacket by posterior straps to keep 
the trunk erect on the props. 

The problem is made more difficult when the arms are in- 
volved because the patient cannot, in that event, use crutches 
easily. But an arm badly paralyzed enough not to be able 
to hold a crutch is fortunately the exception and where the 
use of crutches was necessary for walking no case in the writer's 
experience has been kept from walking by the paralysis of 
the arm because it has been possible in most instances to 
teach the patient to hold a crutch in some form or other. 

That apparatus should be light is essential. It is a great 
burden to weight a weak leg with several pounds of metal and 
a tax on muscles as a rule unable to bear an extra tax. It is 
also necessary that apparatus should fit accurately and be 
mechanically sound. In no department of orthopedic surgery 
is the careful attention to the fit of apparatus so desirable as 
in infantile paralysis. 

Objections to the use of apparatus are evident, because it 
cannot be otherwise than undesirable to put onto a weakened 
limb an apparatus which means extra weight and muscular 
constriction by the bands or lacings required to hold it in 



BALANCE 49 

place. It must be remembered that such apparatus is put on 
only to make walking possible, or to prevent deformity and 
that it should not be worn when not required for walking, that 
is, not continuously except in those cases of long standing 
where further muscular gain is hopeless. 

But granted that apparatus is undesirable the conditions 
which it is put on to prevent are still more undesirable. These 
are (i) inability to walk, and (2) the acquirement of malposi- 
tion and permanent deformity. 

BALANCE 

But between the time when the extensively paralyzed patient 
can stand supported as described and the time when he can 
stand alone or walk with or without crutches, there is one 
absolute necessity, namely he must learn to balance. The 
sense of equilibrium is often greatly impaired by the prolonged 
recumbency and when the patient thus severely affected is 
placed on his feet he is quite unable to keep any balance either 
with or without crutches. 

This is not necessarily a matter of muscular paralysis for in 
a week perhaps, or in two or three, with no especial increase in 
muscular power he may be able to stand on crutches without 
assistance and learn to walk a little. Thus the sense of balance, 
that is the sense of equilibrium must be reckoned with by itself 
as independent of the paralysis and as perhaps one of the first 
needs of the case beginning on ambulatory treatment. 

This was strikingly shown in a case of the writer where a 
woman of twenty-eight had never walked without crutches 
since an attack of paralysis of both legs at the age of three. 
With crutches she could get about but when the legs were con- 
verted into props by means of braces she had no power of 
remaining erect without crutches. Yet in two or three weeks 
she could stand alone and walk a little. 

To repeat, the sense of balance must be reckoned with in all 

severe cases and must be trained by repeated drills in standing 

with crutches and support of the nurse's hands by holding 

onto the furniture, etc., and it must be remembered that 

4 



5o 



TREATMENT OF INFANTILE PARALYSIS 



often the primary difficulty experienced in standing erect in 
proper splints may be due not wholly to the paralysis but also 
to the loss of equilibrium. 

Learning to Walk. — It is thus evident that walking and even 
standing are impossible until the sense of equilibrium has re- 
turned. From that time all attempts at starting on walking 
should be made with such manual assistance as may be 
necessary. 

When standing with braces and crutches but unsupported 
by outside assistance is possible the patient should next be 
encouraged to advance the crutches one at a time and drag the 



Fig. 





Corset for use in paralysis of back or abdomen. 



feet forward to them and then to advance the crutches again 
and again drag forward the feet. A tripod is thus formed 
the two forward supports being the crutches and the legs 
forming the posterior support. 

One essential fact to be remembered in this connection is that 
in severe cases the trunk can flex on the legs to any extent but 
that hyperextension is checked at the hips by the Y ligaments. 
So that in standing and walking, flexion at the hips must be 
guarded against but hyperextension at the hips is not a danger. 
Hence the patient with no gluteal power can walk by dragging 
the legs along behind the body, the center of gravity thus falling 
well behind the hips whose hyperextension is checked by the Y 



GENERAL CONSIDERATIONS 5 1 

ligaments. This is not the case when there is flexion deformity 
of the thighs on the trunk due to contraction of the tensor 
fascia lata as in these cases the center of gravity cannot be 
brought behind the hip-joints and the gluteal paralysis becomes 
then an obstacle to walking and standing. Patients with very 
severe paralysis may never learn to walk in any other way than 
this tripod progression, advancing the crutches and hitching 
along the legs together. 

To walk one step at a time implies some degree of muscular 
power in the muscles controlling the hips and in the drill for 
walking a knowledge of the affected muscles must be accurately 
obtained and the line of least resistance followed. 

It is obviously better that patients should if possible stand 
erect and walk with one leg at a time instead of dragging both 
legs together along behind them with crutches advanced. 

In cases of extensive paralysis of the back and abdomen 
especially if associated as it often is, with involvement of the 
gluteal muscles, a leather jacket is necessary to support the 
back and abdomen and, if gluteal paralysis be also present, 
straps may pass from the back of each splint to the back of the 
jacket, which straps in a way supplement the need of gluteals 
by keeping the trunk from flexing on the legs. In short the 
patient from the axillae down is encased in a stiff apparatus 
which prevents flexion of the legs on the trunk and enables 
walking but of course such straps must be loosened before 
setting down. 

General Considerations as to Treatment at This Stage — 
The considerations so far presented have dealt with the means 
and desirability of promoting the upright position and ambu- 
latory activity at this stage of the affection. A question of 
equal or even greater importance considers what therapeutic 
measures are best calculated to promote the welfare of affected 
muscles and to bring them to their highest efficiency, a question 
of the widest application and of the utmost importance. It has 
been stated that the observations on 300 cases examined in 
Vermont have shown that in all cases, old and recent, infantile 
paralysis has been found in most muscle groups not to be a 
paralysis in the sense of a complete loss of power but a weaken- 



52 



TREATMENT OF INFANTILE PARALYSIS 



ing of these muscles. By manual examination partial paralysis 
bore to total paralysis the proportion of 2.5 to 1 and by the 
muscle test 9 to 1. 

Our therapeutic problem therefore requires the closest pos- 
sible study of such muscles and of the remedial measures by 
which their individual power may be 
increased. 

Moreover as in the earlier stage just 
discussed deformity must still be guarded 
against for its occurrence greatly compli- 
cates treatment and renders it far more 
difficult. 

We have, therefore, before us at this 
stage two primary requirements : (a) the 
prevention of permanent deformity (the 
prevention of early deformity in the 
acute phase having been discussed under 
that heading; and (b) the restoration of 
all possible muscular power to affected 
muscles. 



(a) PREVENTION OF PERMANENT 
DEFORMITY 




Fig. 26. — Talipes equinus 
left foot — 'walking position. 



The prevention of permanent deformity 
at this stage will first be discussed. 
The prevention of deformity is too little insisted on, and 
it is probable that the occurrence of serious hxed deformity is, 
except in paralysis of the spine and shoulder, nearly always un- 
necessary. A competent orthopedic surgeon would, except in 
a very unusual case, be ashamed of the occurrence of serious 
fixed deformity of the foot in any case under his control from 
the early stage of the affection, yet many cases of infantile 
paralysis sooner or later acquire some deformity. In any 
discussion of paralytic deformity it is a very serious part of 
our business to educate the general practitioner, the surgeon 
and the neurologist to the point of recognizing such deformity 
as in general an evidence of neglect. 



DEFORMITY 



53 



As paralytic deformity arises from various causes, it occurs 
in various forms. Intelligent treatment, operative or mechan- 
ical, must start with an analysis of the cause and character 
of the deformity. 




Fig. 27. — Severe talipes varus of right 
foot. 



28. — Talipes varus, left foot, 
moderate in degree. 



DEFORMITY AND ITS STAGES 

There are three stages in the development of deformity in 
infantile paralysis which are as follows: 

1. Constant malposition, in which the limb can still be re- 
placed in the normal position without the use of force. 

2. Adaptive changes in the soft parts, consisting of length- 
ening on the stretched side of the joint, and shortening on the 
other, which occur in most cases which are subject to pro- 
longed malposition. In some cases, however, this does not 
occur and the joint remains flail. 

3. Permanent bony deformity must occur if the malposition 
remains permanent during the years of growth. Bone is an 
adaptive structure, and notably so while developing, because 
in its growth it follows the line of least resistance. The bones 
of the foot, for instance, develop normally only when the foot 



54 



TREATMENT OF INFANTILE PARALYSIS 



is normally used and a persistent valgus, e.g., is followed by a 
distortion of the individual bones of the foot to the type familar 
in the valgus of adults. 

DEFORMITY AND ITS VARIETIES 

Deformity in general may be discussed under two heads: 
i . That due to gravity or weight-bearing in wholly paralyzed 
or flaccid limbs. A leg is wholly paralyzed, and in sitting and 
lying the foot drops into a position of plantar flexion from the 




Fig. 29. — Mild talipes valgus from 
tibial paralysis — right foot. 



Fig. 30. — Talipes valgus from tibial 
paralysis, right foot. 



leverage of the unsupported foot. This is the earliest type of 
distortion to be seen, and exists from the outset of the disease. 

If a leg is paralyzed, or partly paralyzed, below the knee 
without great disturbance of muscular balance, and the patient 
is able to bear weight on it, the unsupported foot then rolls into 
a position of valgus, and stretched soft parts become length- 
ened and shortened ones contracted, making a fixed deformity. 
Another instance of this type of deformity is to be found in the 
relaxed and hyperextended knee accompanying cases of 
extensive thigh and leg paralysis. 

In the arm a similar condition is to be seen when a paralysis 



DEFORMITY 



55 




Fig. 31. — Severe talipes valgus from 
tibial paralysis. 



Fig. 32. — Double talipes calcaneus. 




Fig. S3' — Talipes calcaneo-cavus with extensive leg paralysis. 



56 



TREATMENT OF INFANTILE PARALYSIS 



of the arm and shoulder has occurred and the head of the 
humerus, no longer supported by muscles, is dragged down and 
away from the glenoid cavity by the weight of the arm. 

2. Malpositions due to disturbance in the relative power of 
antagonistic muscles where paralyzed muscles are overcome 
by their unaffected opponents. 

If the anterior muscles of the leg, or most of them, are 
paralyzed, and the posterior escape injury, the non-antagonized 
healthy muscles will by virtue of their tonicity draw the foot 
into a position of equinus and hold it there, and shortened 
muscles will, in time, become permanently contracted, although 
not paralyzed, while lengthened muscles will become perma- 
nently stretched, and a fixed deformity will result. It can be 
predicted in advance, in most instances, what a definite mus- 
cular paralysis will produce in the way of deformity. From 
the study of 635 cases from the Children's Hospital, Boston, 
the following table of deformities of the foot was formulated: 1 



Deformity. 

Varus, 

Valgus, 



Resulting from paralysis of 

Peronei. 

Anterior tibial. 

Posterior tibial. 

Both tibials. 

Flexor longus hallucis. 

Whole leg (weakened) . 

Complete paralysis. 

Anterior muscles, paralyzed or weak. 

Complete paralysis (from dangling). 

Anterior muscles (with persistence of flexor longus 
hallucis). 

Anterior and external group. 

Paralysis apparently complete (toe flexors 
remaining) . 

Anterior and internal muscles. 

Anterior muscles and weight-bearing. 

Posterior muscles. 

Posterior muscles and one or both tibials. 

Other instances of this type of deformity are flexion 
at the knee and flexion at the hip. In the 
former the hamstrings are active and the quadri- 
ceps weakened, in the latter the hip flexors pre- 
dominate over the weakened glutei. 
Lovett and Lucas: "jour. A. M. A.," Nov. 14, 1908. 



Equinus, 
Equino-varus, 



Equino-valgus, 

Calcaneus, 
Calcaneo-valgus, 



DEFORMITY 



57 



There is one deformity which may belong to either or both 
of the above classes. This is a fixed deformity of the trunk 
resulting from an effort to secure equilibrium and is expressed 
as lateral curvature of the spine. This results from paralysis 
of some of the muscles of the back, from paralysis of the 
shoulder muscles and at times from paralysis of the leg 
which leads to shortening or imperfect function. As a 
result of these diverse causes, to maintain equilibrium, an 
asymmetrical position of the spine is necessary, which, in time, 
becomes fixed. That this is not purely the result of the action of 




Fig. 34. — Paralysis of the neck muscles. 



unantagonized non-paralyzed muscles is shown by the fact that 
in paralysis of the muscles of the right side of the back, e.g., 
the convexity of the lateral curve, is sometimes to the right 
and sometimes to the left. If this deformity were the result 
of the action of the non-paralyzed muscles it would always be 
convex to the same side in the paralysis of the same muscles. 

This deformity may occur while the patient is still recum- 
bent and is often evident when the patient first sits up and 
all cases of infantile paralysis should be examined for scoliosis. 

Paralysis of the serratus magnus muscle leads to a curious 
deformity of the scapula, the so-called " angel wing" paralysis. 



58 TREATMENT OF INFANTILE PARALYSIS 

The posterior border of the scapula turns away from the spine 
and is prominent posteriorly under the skin. 

With regard to deformity in general and the importance of 
guarding against persistent malposition the following may be 
said: If, in standing, the foot rolls over into varus or valgus 
position, if the knee becomes hyperextended, if the spine curves 
to one side, these malpositions should be prevented by accur- 
ately fitting braces, or corsets, which maintain as nearly as 




Fig. 35. — Paralysis of right serratus Fig. 36. — Complete paralysis of 

magnus muscle, showing "angel wing" left arm with dropping of head of 
deformity of scapula. humerus. 

possible the normal position and the normal relations. The 
unrestricted use of the muscles in a partly paralyzed leg where 
such unrestricted use means malposition and unbalanced 
function is of little importance compared to the harm done. 
From the point of view of the orthopedic surgeon, therefore, 
who better than any one else knows the late history of infantile 
paralysis, the importance cannot well be over-stated of sup- 
porting from the outset of the disease, so long as necessary, the 



DEFORMITY 



59 



paralyzed limb in its normal position and enabling it to perform, 
as nearly as possible, its function in its normal relations. 

It must be remembered that a muscle may be rendered func- 
tionless by prolonged stretching, and that stretched muscles 
are on the whole more difficult to deal with than are shortened 
muscles, because stretching is detrimental to the welfare of 
muscles, and because stretched muscles cannot on the whole 
be successfully shortened by operative measures. 





Fig. 37.- 



-Paralysis of the right deltoid 
muscle. 



Fig. 38. — Mild paralysis of the left 
arm showing shortening from re- 
tarded growth. 



In the case of the arm the danger of stretching is of par- 
ticular importance on account of the frequent involvement of 
the deltoid muscle. The arm hangs from the scapula sup- 
ported only by the joint capsule ligaments and muscles of which 
the deltoid is most important. If the deltoid is paralyzed the 
head of the humerus tends to drop away from the glenoid cavity 
and to stretch and elongate the capsular ligament, but especially 



6o 



TREATMENT OF INFANTILE PARALYSIS 



to pull on the deltoid and subject it to constant strain from the 
weight of the arm. It is questionable whether this may not 




Fig. 39. — Paralysis of left wrist with the hand falling into the position of ulnar 
deviation induced by gravity. 

be the important factor in making paralysis of the deltoid such 
a formidable and resistant variety. 







Fig. 40. — Paralysis of the right arm with supination contraction. 

It, therefore, is always desirable to support such arms by a 
sling taking the weight of the arm off of the shoulder-joint and 



DISLOCATIONS 



61 



it is even a question whether it might not be wise to support the 
arm at the level of the shoulder at right angles to the body 
by means of a platform splint to allow the deltoid fibers to 
shorten. The very unsightly character of the method however 
will always prevent its general use. 

Finally, with regard to deformity a definite rule may be 
formulated which will be repeated later which deals with a 
matter of great practical importance often overlooked. The 
presence of a fixed deformity is an obstacle to any treatment either 
by apparatus, muscle training or operation to improve function. 
The two questions that of the 
prevention and that of the cure 
of fixed deformity are among the 
most important in the whole 
subject. 

DISLOCATION OF PARALYZED 
JOINTS 

Dislocation as a result of the 
paralysis is occasionally met and 
true dislocation occurs practically 
only in the hip. The humerus 
may drop away from the glenoid 
cavity in severe paralysis of the 
shoulder but this is not a true 
dislocation but simply a stretch- 
ing of the joint capsule and is 
a gravity deformity. 

Paralytic dislocation of the 
hip, however, is a true dislocation, 
which is sometimes disabling and 
it has been somewhat studied. 

It occurs as a subluxation in which the joint is merely unstable 
and slips out a little when the leg is adducted or the head of the 
bone is dislocated quite out of the socket. The most common 
form is an upward and backward dislocation, the infrapubic 
or forward dislocation having been reported. 




Fig. 41. — Dislocation of the left 
hip from infantile paralysis. 



62 TREATMENT OF INFANTILE PARALYSIS 

The stretching of joint capsules in infantile paralysis is well 
known and as the hip- joint is deeply seated it is normally 
rarely dislocated. When, however, the intrinsic muscles of the 
hip are paralyzed, the glutei weakened or paralyzed, and the 
adductors and tensor fasciae femoris less affected or contracted, 
the mechanism is at hand for the head of the femur to slip 
out in adducted positions of the leg. Flexion deformity of 
the hip is, therefore, to be regarded with suspicion and it 




Fig. 42. — Coxa valga and tendency to subluxation of hip due to infantile 
paralysis. Duration nine years. (Sever.) 

makes it advisable to relieve these flexion contractions at the 
hip, where they occur, as early as may be practicable. 

The subluxation or luxation is not apparently traumatic but 
gradually appears and is characterized by instability, shortening 
and sometimes pain in walking. In one class of cases the dis- 
located bone forms a new and stable socket for itself and the 
shortening is the chief annoyance. In other cases the leg 
becomes much shorter than the other, the head of the femur 



DISLOCATION OF THE HIP 



63 



fails to make a firm new socket and an exceeding unstable and 
irritable hip-joint results. Atrophy and practical disappearance 
of the head of the dislocated femur may occur. When the 
condition exists which allows a troublesome dislocation of the 
hip there seems but little to do except to perform an arthrodesis 
at the hip-joint, an operation to be discussed later. Attempts 
to hold the hip abducted by a spica of plaster of Paris to enable 
the capsule to shorten in the milder cases and reduction of the 




Fig. 43. — Coxa valga and subluxation of hip of eleven years' duration. The hip 
was dislocated at every step; a successful arthrodesis was performed. (Sever.) 

dislocation by a " bloodless" manipulation have, in the writer's 
hands, always failed, nor is this surprising if one bears in mind 
what has been said of the mechanism of the production of the 
dislocation. The remedy of conditions known to favor disloca- 
tion is, however, to be recommended. 1 

1 J. W. Sever: ''Boston Med. and Surg. Jour.," Aug. 31, 191 1. 

Karewski: ''Ann. Surg.," 1889, x, 226. 

Bocher: "Verhdlg. Deutsch. Ges. f. orth. Chir." Apr., 1909. 

Cramer: "Archiv f. orth. etc.," ix, 1, 1910. 

Riedinger: ''Archiv f. orth. etc.," viii, in, 1910. 



6 4 



TREATMENT OE INFANTILE PARALYSIS 



The diagnosis of such dislocations is generally made by feel- 
ing the head of the femur slip partly or wholly out of the 
acetabulum in adducted positions, by shortening of the leg, 
by elevation of the trochanter above Nekton's line in superior 
dislocation and by the x-ray, the most valuable means of all. 




Fig. 44. — Recent dislocation of hip from infantile paralysis. 

(6) RESTORATION OF NERVE AND MUSCLE POWER 

Having this discussed the acute phase and its treatment, 
and having spoken of the beginning of the convalescent phase 
and the origin and causes of deformity, it becomes necessary 
to discuss next what measures may be used to preserve and 
restore the greatest ultimate amount of power to affected 
muscles. Certain fundamental facts must be noted as a 
result of the spinal cord lesion, already described. Many 



FATIGUE 



65 



muscles have lost some, and a few muscles have lost all of their 
power of contraction, and as a result of this, or as the result of 
an involvement of the trophic centers of the cord, the nutrition 
and circulation of these parts are impaired. 

Fatigue. — The well-being and efficiency of a muscle is 
largely dependent on the performance by it of a certain number 




Fig. 45. — Dislocation of the hip due to infantile paralysis. The head of the femur 
has gradually absorbed. The case has been under observation twenty years. 

of active contractions. When a normal muscle is inactive 
for any length of time it atrophies. It is an accepted phy- 
siological principle that the exercise of the normal functions of 
a muscle is the best means of increasing its size and strength. 
It is a well-known practical experience, however, that a muscle 
may be given so much work to do that weakening and atrophy, 
instead of strengthening and increased size, will result. 



66 TREATMENT OE INFANTILE PARALYSIS 

This is to be explained by physiological experiment, which 
has found that a muscle which has been made to contract until 
it has reached its fatigue point takes a number of hours to 
recover its former ability to do work. If, after it has reached 
the fatigue point, it is still further stimulated, the length of time 
taken for it to recover is measurably greater, and if the 
stimulation is continued for some time after the fatigue point, 
recovery may never take place. The problem then is to find 
out just how much work is beneficial to the muscle we wish to 
develop in order that we may avoid giving it the dangerous 
overdose. 

We have been speaking of the development of the normal 
muscle, but the same rule undoubtedly applies to the partially 
paralyzed muscle, except that in the case of the latter the 
danger of overwork is much greater. 

Aside from this theoretical consideration it has been found in 
practice that overwork of muscles weakened by infantile 
paralysis is seriously detrimental and retards recovery. 
Clinical observations were confirmed by the muscle test espe- 
cially in cases in private practice watched by frequent tests. 
It has been found by these tests that many paralyzed children 
who were doing very little in the way of walking were obviously 
damaging their muscles. Indeed it has been difficult to realize 
that so little walking could do harm, but as these patients have 
been more and more restricted in activity the rate of improve- 
ment has been faster. In the writer's opinion one of the serious 
defects of treatment is that patients are encouraged to do too 
much, are allowed too much activity and frequently receive 
too much therapeutic exercise and massage. It is apparently 
desirable that patients in their first year of the disease should 
get about and become accustomed to the upright position; it is 
essential for good progress that they should have therapeutic 
muscular exercises to develop weakened muscles and establish 
new paths from brain to muscle. Fatigue to weakened muscles 
is dangerous and detrimental and underuse of such muscles is 
safe. The avoidance of fatigue must be insisted on as an essen- 
tial to the best progress no matter what restriction of activity 



FATIGUE 67 

it may mean. A quotation from a paper of the writer's may 
make the matter more specific. 

It has been repeatedly observed in my private practice that power 
might begin to return in a very faint degree to a muscle while under 
muscle training, and that with care this power would steadily increase, 
but if that muscle were exercised even very gently every day, that power 
would diminish or disappear, so that we exercise such muscles only once 
in three days at the outset, increasing the work most carefully. . . . 

Illustrative cases seem to me to show that much smaller degrees of 
overuse may be deleterious than is generally supposed. Probably any 
of us would agree that gross and persistent overuse of partly paralyzed 
muscles would be undesirable; but it seems to me reasonable that in the 
early stage of returning power, we should be exceedingly careful in the 
use of muscles in walking and in the use of heavy and prolonged massage, 
much more careful than we are at present, if I may judge the practice of 
others by my own previous methods. 

This matter was confirmed and made more definite by the mus- 
cle test. Illustrative cases follow: 

Case i. — A boy of five, in the Vermont series with the onset in 19 14, 
was having at the time of the first test one and one-half hours of massage 
and one hour of muscle training daily. This was changed, and he was 
given one hour only of gentle muscular exercise, and the second obser- 
vation showed a substantial gain of strength in all affected muscles, an 
illustration of the effect of too much treatment. 

Case 2. — A boy with the onset in 19 14, in July showed partial par- 
alysis of the left arm. He then began to milk ten cows daily, and in a 
month had lost strength in all of his left arm muscles except the biceps and 
triceps, which had gained slightly. The loss was greatest in the muscles 
of the forearm, which were of course those most exercised in milking, an 
illustration of the effect of overuse of the muscles as a cause of loss of 
power in the overused muscles. 

Case 3. — A man of twenty-two was referred in the fourth week after 
his onset. He had involvement of the right leg and arm, walked with a 
limp and could not raise his right arm. The left arm appeared to be 
slightly weakened. Examination by the usual method showed extensive 
weakness in the left arm, very little power in the right deltoid, and a general 
involvement of the right leg. His right arm was put in a sling, he was 
cautioned against much walking and the use of the arm, and weekly 
muscle tests were made, showing a general slow gain, but no therapeutic 
exercises were allowed at first. At a test, October 4, an increase of 50 
per cent, in the power of the right gastrocnemius muscle was observed, 
and on questioning it was found that he had been daily rising on his toes 
as a trial. This seemed to indicate that he was ready for therapeutic 
exercise, on which he then began with success. The test, October 26 



68 TREATMENT OF INFANTILE PARALYSIS 

showed a loss of 25 per cent, of power in the wrist and finger flexors of the 
right hand, and it was found on questioning that he had been writing 
too much. , This was stopped, and on the following week a return of the 
former power was found in these muscles, an instance of the information 
afforded by the test in directing routine and defining treatment. 

Case 4, — A girl aged eight and one-half, affected in 19 13 with ex- 
tensive paralysis of both legs, was walking with splints and crutches, 
and her muscle power was on the increase under daily muscle training. 
Nov. 18, 191 5, there was a general loss of power in the legs. On question- 
ing it was found that relatives had been visiting the family, and the 
child had been doing much more than usual, an instance of the deleterious 
effect of local and general fatigue. 

The therapeutic measures to be considered at this stage are: 
. (a) Massage. 

(b) Heat. 

(c) Electricity. 

(d) Muscle training. 

(a) Massage. — The favorable action of massage on parts 
affected by infantile paralysis is undoubted and is to be recog- 
nized but also it must be recognized that it has distinct limita- 
tions and that too much must not be expected of it. The 
proper stroking, kneading and manipulation of an affected 
limb stimulates the flow of venous blood toward the heart by 
mechanical emptying of the veins, which incidentally increases 
the flow of arterial blood to the limb to replace the venous blood 
carried away. Massage also facilitates the flow of lymph 
toward the center of the body by mechanical emptying of the 
lymphatics. Direct manipulation of the muscles also must 
in a measure empty them of waste products retained in the 
muscles themselves. These measures all tend to improved 
circulation of blood and lymph in the affected parts and conse- 
quently to improved muscular nutrition and tonicity of the 
muscles massaged, and thus probably retard and diminish 
muscular atrophy by inducing better nutrition locally. On 
the other hand, the overuse of massage, i.e., the use of too long 
or too rough manipulation, causes muscular fatigue, increases 
muscular atrophy and diminishes muscular tone. 

It therefore can only be expected of proper massage that it 
will improve locally muscular tone and nutrition and antagonize 



USE OF HEAT 69 

muscular atrophy and nothing more. It will not restore 
muscular power except in this way and it has no direct effect 
on the disease nor on the transmission of nerve impulses from 
brain to muscle. 

Vibration should be classed as mechanical massage and is 
given by means of an apparatus which produces locally a suc- 
cession of rapid blows to the tissues. It apparently is effective 
chiefly by acting on the vasomotor nerves which are stimu- 
lated to bring more blood to the part. It is also probable that 
the direct mechanical effect on the muscle of a series of blows 
is not to be neglected because it is well known that a blow 
to the belly of a muscle causes a contraction of the fibers. 
A succession of mild blows would therefore probably tend 
toward increasing muscular tonicity which is of course desirable. 
Practically vibration in connection with massage seems to make 
the latter somewhat more effective. 

(b) Heat. — If a partly paralyzed limb is heated it is capable 
of performing better muscular function than before. This is 
due apparently to two causes: first, to an elevation of the 
temperature of the muscles to a point more favorable to 
muscular activity; and second, to a stimulation of the circula- 
tion. Muscles work better the higher the temperature up to 
the point of injury from heat. The maximum temperature 
limit of normal life may be put at about n6°F. and heating the 
muscle has a direct specific effect upon its activity. 

Moreover, the heat causes a reflex dilatation of the surface 
capillaries in the skin which causes a flush and draws the blood 
out of the deeper parts. This is succeeded by a contraction of 
surface capillaries and a dilatation of deeper vessels so that the 
flow of blood in the affected limb is stimulated and this also 
adds to temporary muscular effectiveness. 

But apart from its use above, the heating of the limb appar- 
ently adds to the effectiveness of massage because if the mas- 
sage is given directly after the heating while the superficial 
capillaries are full of blood, a greater volume of blood is probably 
driven toward the center of the body to be replaced by a similarly 
large volume returning to the limb. 

Heat may be applied as radiant heat or non-radiant heat. 



70 TREATMENT OE INFANTILE PARALYSIS 

Radiant heat is given off from electric light bulbs with carbon 
filaments arranged in some reflecting cone or hemisphere. This 
form of apparatus is simpler, and more easily handled than the 
various hot air ovens and does not require preliminary heating. 
Whether radiant heat possesses more desirable qualities than 
non-radiant heat is not established. 

Where special apparatus is not available an ordinary oven or 
even open fire may be utilized to warm, the limb. In a large 
sheet of asbestos board a hole is cut and the leg put through 
the hole into the moderately heated oven or close to the open fire, 
the sheet of asbestos board protecting the patient from the heat. 

Hot water is a less desirable form of heat, as it makes the 
skin tender and cannot be borne at so high a temperature as 
can the dry heat. 

If the process of heating is too long continued the reaction 
fails to occur, so that ten to fifteen minutes is long enough. 
The temperature may be as high as the patient can bear 
without discomfort. 

In virtue of the fact that muscles perform better function when 
warm, the paralyzed limbs should always be warmly clothed. 
Heavy stockings and long undergarments should be worn in 
the winter. An arm may be wound in cotton wadding or an 
extra sleeve may be used. Chilling of the affected parts is 
always bad and children using wheel chairs in winter should 
not only be warmly protected with rugs but the feet should rest 
on a hot water bottle. 

(c) Electricity. — Electricity has been in the past very 
extensively used in the treatment of infantile paralysis and 
today, although the subject of much controversial argument, it 
has been until recently at least, probably the most generally 
used form of treatment, especially in the hands of the general 
practitioner. The reason for its general use has seemed to 
consist in a general impression that it would do good in some 
mysterious way not clearly formulated. But a closer analysis 
is necessary if one is to arrive at any estimate of its value. 1 
Several kinds of electricity are advocated. 

1 Sachs: "jour. A. M. A.," Nov. 5, 1910, p. 1663. 
Diller: "Jour. A. M. A.," Oct. 22, 1910. 



ELECTRICITY 7 1 

The faradic current acts directly on the muscle to which it 
is applied to produce a local contraction. If the muscle is not 
wholly paralyzed this takes place and is theoretically of benefit 
when contraction of a given muscle cannot be produced 
voluntarily. But it is evident that it is not a very powerful 
means of exercise and practically it is disagreeable to the 
patient, and to young children a source of terror. It seems as 
if it were a legitimate means of giving to certain muscles a 
mild contraction repeated a few times, but that it can be 
regarded only as a means of gentle occasional exercise and too 
much must not be expected from its use. 

The galvanic current, on the other hand, is used to improve 
nutrition, to promote the conduction of nerve impulses, and 
for an indefinite general effect on the nervous system which its 
advocates believe it to have. It is obvious that the matter 
of proving this is not easy, if possible at all, and one must 
judge largely if not wholly empirically. In this case personal 
experience must be drawn on and the writer has never been 
convinced in trials lasting over many years that galvanic 
electricity was of the least use in any individual case. It has 
been repeatedly used on a patient's right or left side in cases 
of symmetrical paralysis and the assistant who was giving 
daily muscular exercises and massage was not told which side was 
receiving the electricity and at the end of two months she has 
been asked if she had noticed a different rate of improvement 
on the two sides and if so which side showed most. In no in- 
stance has the side treated by electricity showed a faster rate of 
progress. It has not been possible as yet to test out the progress 
of cases thus treated by means of the spring-balance muscle test. 

But aside from galvanic and static electricity of late the 
newer forms of current have been advocated, such as high- 
frequency, the sinusoidal currents, the Morton wave current, 
etc. The working of these and their rationale is even more 
obscure than in the case of the galvanic current. 

The reasons for the use of the high-frequency current for 
example are given as follows: 1 

1 Frauenthal and Manning: "infantile Paralysis," F. A. Davis, Philadelphia, 
1914. 



72 TREATMENT OF INFANTILE PARALYSIS 

"I cannot attribute the results obtained wholly to the vasoconstrictor 
action of the high-frequency current and consider that the blood-vessel 
walls are rendered less permeable, and that the transudation of fluids 
and the migration of cells are checked by a direct oxygenating and vivify- 
ing influence of the venous blood. I consider this oxygenation of suf- 
ficient power and extent to partly or wholly sterilize the invaded tissues 
in a similar manner to the electric sterilization of water." 

and with regard to electric stimulation in general : 

"Electrical stimulation of the ganglionic neuron through its peripheral 
branch directly improves local nutrition, increases the caliber of the 
nerve of conduction, manifolds energy transmission thus securing com- 
pensation for the decrease in muscle mass." 

Those persons to whom this type of physiology and pathology 
appeal will find no difficulty in satisfactorily explaining the 
benefits likely to be received from the use of electricity. 

It can only be repeated that the evidence that such forms of 
electricity are of benefit rests at present almost wholly on the 
statements of personal experience. 

There is, however, some purely experimental evidence that 
electricity retards loss of weight in denervated muscles. Langley 
and Kato in 191 5 1 published the results of some experimental 
work dealing with the rate of loss of weight in muscles after 
nerve section with observations on the effect of stimulation 
and other treatment. 

It was found that stimulation of a denervated muscle through 
the skin caused only the superficial fibers to contract unless 
strong currents were used and the experiments tended to show, 
"although they were not numerous enough to give decisive 
results," that electrical stimulation with condenser shocks 
delays the atrophy. 

"It is practically certain that if electrical stimulation has a beneficial 
effect, the optimal effect will be with that current which is strong enough 
just to cause contraction. In the ordinary methods of stimulating 
muscles through the skin, whether by unipolar or bipolar methods, with 
currents of long or short duration, the intensity of the current is much 
greater in the superficial than in the deep fibers, and we think it doubtful 
whether the latter can be stimulated without using currents injurious to 
the former." 

1 "journal of Physiology," xlix, p. 432. 



ELECTRICITY 73 

These observations it must be remembered were made on 
denervated muscles and not on those affected by infantile 
paralysis. 

With regard to the generalizations made as to the use of elec- 
tricity, it must be remembered that practically all cases 
improve after the acute attack is ended, that 25 per cent 
recover spontaneously in four years (Massachusetts State 
Board of Health figures) and that no one can foretell in a 
given case how rapid or how slow the improvement will be. 
Under these circumstances loose generalizations as to any form 
of treatment are likely to be misleading and only closely 
checked quantitative observations on muscular strength or a 
very extensive clinical experience with all methods would make 
such generalizations of any value. 

Electricity used in proper doses probably does no harm 
locally and perhaps some good, but it often does harm by mak- 
ing the parents and the practitioner believe that the patient 
is being efficiently treated while the other important and 
really useful means of treatment are being neglected. In 
this way electricity has done an indefinite amount of harm by 
taking the place of other measures during the critical period of 
convalescense. The use of too strong electricity may be 
detrimental. In short, the belief of the writer founded on 
experience of treatment with and without electricity is that 
faradism is a means of inducing mild muscular exercise, and 
possibly in that way somewhat useful. That galvanic elec- 
tricity and the newer currents have not been proved to be of 
value and in his experience have not appeared to be of any 
value whatever, but in his opinion when, parents have heard 
of the wonders of electrical treatment and desire to use it they 
should be encouraged to do so provided they use at the same time 
the other treatment, the value of which is universally admitted. 

(d) Muscle Training. — The importance of muscle training 
and of the muscular examination leading up to it is so great 
that these subjects will be considered in a chapter by themselves 
(see page 123). 



CHAPTER IV 
TREATMENT 

THE CHRONIC PHASE— SHORTENING— LAMENESS— CORRECTION 
OF DEFORMITY— DEFORMITY AT THE ANKLE— DEFORMITY AT 
THE KNEE— DEFORMITY AT THE HIP— SCOLIOSIS— DEFORMI- 
TIES OF THE UPPER EXTREMITY 

In the chronic phase the tendency toward spontaneous 
improvement may be assumed to be slight, although the 
Vermont figures have shown that it goes on much longer than 
had been commonly supposed. It is the stage of stationary 
paralysis and the time when fixed deformities become evident 
and when the operative question arises. The mechanical 
needs of the paralyzed limb from a therapeutic point of view 
are much the same as they were before and the patient with a 
paralyzed quadriceps muscle will still need a brace, and the 
advisability of massage and muscle training still exists although 
holding out less favorable prospects than in the previous phase. 
It is a stable state of affairs when we can quietly decide what is 
best to be done, one need not wait longer. 

The treatment in this stage has in late years very properly 
become much more operative than it formerly was on account 
of the rapid development of this very promising field in ortho- 
pedic surgery and this development has changed the outlook 
for many paralyzed patients. But it must always be borne in 
mind in this matter that the most experienced operators in this 
line of work in all parts of the world advise against operation 
in less than two or three years after the acute attack except 
for minor tenotomies, etc. 

SHORTENING 

This is an important matter frequently overlooked in the 
treatment of cases at this stationary stage of the disease, a 
matter which demands close attention if one is to obtain the 
best results in paralysis of the leg from any treatment. 

74 



CORRECTION OF DEFORMITY 75 

Where shortening exists to any degree it is desirable to esti- 
mate and correct it by building up the short leg. It is unde- 
sirable for the growing child to be standing with the pelvis 
always inclined obliquely and a consequent lateral spinal curve, 
as must be the case when one leg is decidedly shorter than the 
other. Moreover, to walk with much shortening throws the 
muscles of locomotion out of balance, and in addition to the 
ungainly walk is in some cases detrimental to some of the 
muscles about the hips. Shortening of a quarter of an inch is 
of no importance, but when it gets to be more than half an 
inch it is generally desirable to correct it at least in part by 
raising the sole on the shortened side. As a rule the full correc- 
tion is not well borne, at least at first, and one must experiment 
to find out just the amount with which the patient walks best. 
The question of shortening is entirely independent of whether 
or not a brace is worn and is as important after an operation as 
before it. 

LAMENESS 

At this stage the lameness will have become fixed and char- 
acteristic and this subject is considered in another place in 
connection with the examination preliminary to muscle training 
(page 123). 

OPFRATIVE TREATMENT 

This is properly undertaken for two conditions: (i) the cor- 
rection of fixed deformity; and (2) the improvement of func- 
tion. These will be next considered in the order named. 

THE CORRECTION OF DEFORMITY. PROCEEDINGS OPERATIVE 
AND OTHERWISE 

The term fixed deformity applies to a condition where a joint 
cannot be moved passively through its normal arc, that is where 
there is some restricting limitation to full motion. 

A general rule of much importance has been stated to the 
effect that no treatment mechanical or operative should be under- 
taken till fixed deformity is relieved. This, of course, does not 
apply to operations undertaken for the cure of deformity. 



76 TREATMENT OE INFANTILE PARALYSIS 

In general, stretching of contracted tissues is preferable to 
cutting them as it better preserves muscular balance. To 
cut a tendo achillis, e.g., means that after recovery the muscle 
will have a longer tendon and shorter belly than before, whereas 
if the same lengthening is obtained by stretching, the propor- 
tion of belly and muscle are preserved. This consideration, 
however, in no way militates against cutting operations when 
they are necessary. Simply, if stretching will do the same as 
cutting, even if it takes longer, it is better. 

The individual fixed deformities will next be considered and 
discussed. 

DEFORMITY OF THE ANKLE 

Equinus. — This is of all the deformities of infantile paralysis 
the most frequent not only because at the ankle the paralysis is 
more common and more severe than elsewhere in the body but 




Fig. 46. — Method of stretching contraction of the tendo Achillis. 

because during the acute attack the child is too often allowed to 
lie with the bedclothes holding the foot in plantar flexion, and in 
sitting the foot hangs and continues in this same position of 
dropping. Under these conditions an adaptive shortening or a 
shortening due to muscular contraction occurs, in which the 
posterior muscles become contracted and the anterior muscles 
stretched% This deformity may occur in the first weeks of the 
acute attack, and from the onset should be guarded against. 
When it has become fixed it constitutes a serious obstacle to 
standing and walking, and requires correction before mechan- 
ical or other treatment is likely to be successful. 

A new means of correcting it, which has proved most efficient, 
is to put on a plaster-of-Paris circular bandage reaching from 
the toes to just below the knee. In putting this bandage on 



DEFORMITY AT THE ANK^LE 77 

the leg is fully flexed on the thigh in order to relax the gastroc- 
nemius muscle and allow as much dorsal flexion of the foot 
as possible. When the plaster has become dry which takes 
about twenty-four hours, an elliptical piece is cut out over the 
front of the ankle joint in the flexure between the foot and the 
leg, embracing about two-thirds of the circumference of the 
cast at this point. A webbing loop is then put around the 
foot and another around the top of the cast, and these two 
webbing loops are connected by another webbing strap 
furnished with a buckle, by which continued tension may be 
made upon the foot, pulling it into dorsal flexion with any 
desired degree of e version or inversion of the sole. In recent 
cases this method of treatment will correct the deformity often 
in five or six days, and in older cases often within two or three 
weeks. It is surprising what degree of equinus may be cor- 
rected by this method without much discomfort, but occa- 
sionally a case proves utterly resistant to the method (Fig 46). 
Operative Measures. — With regard to operative measures 
for equinus, these should be undertaken with great care for 
two reasons. In the first place a patient with equinus and 
with poor anterior muscles is likely to have after tenotomy a 
worse foot than before, because if the anterior muscles do not 
have any power to regain, the foot becomes flail-like and is 
often of less use after operation than before because it is loose 
in both plantar and dorsal flexion. It is therefore a sound rule 
not to divide the tendo achillis in paralytic talipes equinus 
unless there is evidence of fair power in the anterior muscles, 
or unless an anterior silk ligament is put in to prevent foot- 
drop. A second caution of equal importance in this con- 
nection is that with a weak quadriceps it is, as a rule, poor 
surgery to divide the tendo achillis when talipes equinus is 
present, because a patient with a weak quadriceps and a mild 
equinus can walk without a brace, the knee locking back and the 
quadriceps being thrown out of action, whereas if the equinus 
is removed the patient will be unable to walk without a brace. 
It is therefore again to be recommended most carefully that 
tenotomy for paralytic talipes equinus should be done only with 
great care and in accordance with the restrictions given above. 



78 TREATMENT OE INFANTILE PARALYSIS 

If an operation is desirable it is a matter of no consequence 
whether the tenotomy is a simple subcutaneous tenotomy or 
one of the more elaborate tendon lengthenings such as the 
Bayer operation. If a tenotomy is performed, after operation 
the foot should be placed at a right angle to the leg and put up 
in a plaster-of-Paris circular bandage, and kept in this position 
for preferably six weeks. This unusually long time is men- 

____ tioned in order to allow the stretched 

I anterior muscles to recover such power 

as they may, and to have an oppor- 
tunity of becoming shortened. It is a 
common experience in properly selected 
cases to find a very decided improve- 



FlG ' 4? tTn^tomy ^^ ment in the P 0Wer ° f the anterior mus ~ 

cles after tenotomy. 

Other Deformities of the Foot. — With regard to talipes varus 
and valgus, that is, the inverted and everted positions of the 
foot which occur occasionally in infantile paralysis, the simple 
correction of the deformity by tenotomy or manual force is 
of no special use, because it will recur again from the same 
causes which made it occur in the first place. The correction 
of deformity here should figure in most cases merely as a 
preliminary to some operative procedure intended to prevent a 
recurrence of deformity. 

It has been said earlier that tendon grafting and similar 
operations should only be undertaken in a foot whose de- 
formity has been corrected. It is possible in most cases to 
correct the deformity at the time of operation before doing 
the tendon grafting or similar procedure. In other cases 
where the deformity is very severe it seems wiser to perform the 
operation in two separate stages at different times. These 
two stages are (i) the correction of the deformity, and (2) 
the tendon transplantation or other procedure. 

The correction of the deformity would be accomplished by 
manual force, supplemented or not by tenotomy or fasciotomy. 
The foot would then be allowed to recover from its traumatism 
after which the tendon transfer may be performed. If an 
astragalectomy, arthrodesis or other operation involving the 



DEFORMITY AT THE KNEE 79 

removal of bone be decided on the deformity can be corrected 
at the time of the bone operation. 

DEFORMITY AT THE KNEE 

There are three deformities found at the knee in infantile 
paralysis: (i) flexion deformity, (2) knock-knee, and (3) hy- 
perextension of the knee. 

Flexion Deformity. — With regard to flexion deformity, this 
is due to the predominance of the flexor muscles over the ex- 
tensors, with the contraction of the knee in a bent position as 
a result. This deformity may or may not be accompanied by 




Fig. 48. — Severe infantile paralysis of nine years' duration. Attitude in lying 
showing severe scoliosis. There is also present contraction of both hips, both 
knees, double knock-knee, severe equinus of one foot and paralysis of on arm. 
Never treated. 

talipes equinus and hip flexion although the association is 
frequent. It may occur early in the disease, in this case 
generally being acquired during the tender stage, or it may 
appear later as a result of the predominance of the posterior 
muscles. 

It is less frequently necessary to do a cutting operation in 
this deformity since the method of wedging was adopted. In 
this proceeding a circular plaster is applied to the leg in the 
deformed position, reaching from the groin to the toes. It 
is made rather heavy over the knee, and after it has dried, a 
transverse division of the plaster is made at the level of the 
knee covering the posterior two-thirds of the plaster, that is to 



8o 



TREATMENT OF INFANTILE PARALYSIS 



say, a transverse division of the plaster on its posterior aspect. 
This opening is then wedged open by a thin piece of wood, such 
as a throat stick, and the wedging is then progressively in- 
creased until the knee is straight. If done with care the pro- 
ceeding is attended by very little pain or discomfort. Recent 
deformities of the knee can be corrected in a few days, and the 
moderately serious ones within three or four weeks as a rule. 
The severe and long-standing cases will require many weeks 
but some prove resistant to full correction by this method. 

This method is preferable to attempting to stretch the knees 
by means of a splint. In case of a very resistant deformity, 
which would be uncorrected by this means of stretching, division 




Fig. 49. — Front view of case seen in Fig. 48. 



of the hamstring tendons would be required, which should be 
performed by the open incision rather than by subcutaneous 
tenotomy. 

Attempts at forcible straightening of such flexed knees under 
anesthesia without cutting tendons are well enough in the 
more recent cases with no great deformity where wedging cannot 
for any reason be carried out. But in cases of marked flexion 
which are of moderate or long duration it must be remembered 
that there is some subluxation of the tibia on the femur due to 
the continual pull of the hamstring muscles, and that a forcible 
straightening alone, is likely to produce a straight leg with the 
tibia in a line posterior to the femur, in other words, in a position 



DEFORMITY AT THE KNEE 



8l 



of subluxation. This is less likely to occur in the wedging pro- 
cess because the posterior muscles apparently yield slowly and 
are thus less likely to cause subluxation (Fig. 52). 

It is well to remember that in severely flexed knees of long 
duration, a knock-knee may appear when the leg is straight- 
ened. Knock-knee is never evident in a flexed knee, being a 
deformity only of the lower articular surface of the femur and 
not of its posterior surface. So that in the flexed position such 
deformity is not present but may be very evident when the 
knee is straightened by any of these methods. 





Fig. 50. — Method of wedging knee for flexion contraction. 

In severe and intractable cases of knee flexion of many 
years standing with marked bony deformity an osteotomy 
above the condyles may be necessary but never should be 
performed before adolescence. 

Knock-knee. — With regard to knock-knee, children with 
extensive infantile paralysis of the legs are likely to acquire a 
knock-knee, the mechanism of which has never been quite clear. 
This knock-knee does not in its end result differ essentially 
from the knock-knee of rickets except in its etiology. It is not 
only unsightly, but if it becomes very severe is likely to make 
the use of splints difficult on account of the internal prominence 
of the knee. In younger children this can be controlled and 
perhaps cured in the milder cases by the use of a splint pressing 

6 



82 



TREATMENT OE INFANTILE PARALYSIS 



outward upon the inner condyle of the knee. In cases of 
longer standing, where it becomes a serious disability, Mac- 
ewen's osteotomy may be done just as in rachitic knock-knees. 
This consists in partial division of the lower end of the femur 
from the inner side just above the inner condyle of the femur, 
and by means of reasonable force fracturing the knee into a 
straight position. The difficulty about the operation is that 




Fig. 51. — Severe double knock-knee 
from old infantile paralysis. Most 
marked on left side. 



Fig. 52. — Knee formerly contracted 
in flexion and straightened under ether 
showing subluxation of tibia persisting. 



the circulation and the innervation in cases severe enough to 
have acquired a knock-knee of this grade are none too good, 
and although fractures unite perfectly well, it would mean a 
long disuse of the leg and possibly some impairment of function. 
It is on the whole a proceeding not to be lightly undertaken, but 
perfectly proper if it becomes necessary for function. 

Hyperextension of the Knee. — If this deformity, which is 
generally due to paralysis of the quadriceps muscle combined 



DEFORMITY AT THE KNEE 



83 



with weak or paralyzed hamstring muscles, is allowed to per- 
sist uncorrected, the knee not only bends further and further 




Fig. 53. — Hyperextension deformity 
of both knees from double quadriceps 
paralysis. 



Fig. 54. — Hyperextension deformity of 
left knee from quadriceps paralysis. 




Fig. 55. — Flexion deformity of both hips. 

backward but becomes loose laterally. No operation short of 
arthrodesis, which is generally undesirable, is of any value, but 
the use of a brace to prevent hyperextension of the knee is 



84 



TREATMENT OF INFANTILE PARALYSIS 



desirable. In cases where in walking the knee hyperextends 
even to a slight extent the use of a brace, such as the caliper 
described with a posterior strap, checking hyperextension is 
desirable and, if constantly worn, slight cases of hyperex- 
tension weakness may often be cured of the deformity. If 
not treated such hyperextension may reach a high degree as 
shown in the illustrations. 



DEFORMITY AT THE HIP 



Probably the most troublesome deformity except scoliosis in 
infantile paralysis consists of a flexion deformity of the hip due 
to a contraction of the tensor fasciae femoris muscle, which may 




Fig. 56. — 'Extensive paralysis of both legs with flexion contraction at hips and 
knees and extreme double talipes equinus. 

exist alone or with flexion deformity of the knee and equinus of 
the foot. In these cases the thigh cannot be extended fully 
upon the body either actively or, passively because of the flexion 
deformity in the hip, and the correct upright position becomes 
impossible either with or without braces. If the child lies on 
the back and the knee is straightened and made to touch the 
table, just as in tuberculosis of the hip with ankylosis in flexion, 
the lumbar spine rises and the patient allows the knee to come 
to the table by means of an extreme lordosis. If the leg is 
again raised, the back comes flat on the table. The deformity, 
however, is a combination of abduction and flexion, so that if 
the leg is abducted at the same time that it is fully extended 
less resistance is encountered. This is a source of much in- 
accuracy in treatment and diagnosis, because it must be re- 
membered that to estimate fully the degree of flexion present 



DEFORMITY AT THE HIP 



85 



the leg must be extended in the long axis of the body and not 
in an abducted position. 

When the deformity coexists with flexion of the knees 
and plantar flexion of the feet it is a crippling affection pre- 
venting the patient from standing erect, and the hip element is 
the hardest of the three to correct. When the hip deformity 
exists alone in a moderate degree the patient can stand erect 
but with a greatly inclined pelvis and a severe lordosis, be- 
cause this is necessary in order to get the feet to the ground. 





Fig. 57. — Contraction deformity 
at left hip with contraction of left 
knee in flexion, talipes equinus of 
left foot. 



Fig. 58. — Contraction deformity of left 
hip showing position in standing with in- 
creased lordosis. 



Treatment by Stretching. — The deformity in many- instances, 
even in some cases of many months' duration, can be removed 
by prolonged stretching, but operation is simple, so that except 
in young children the discomfort and prolonged recumbency of 
the stretching hardly seem worth while. 

If stretching is attempted the patient should have traction 
on the affected leg or legs and lie on a bed frame. The pelvis 



86 



TREATMENT OF INFANTILE PARALYSIS 




is gradually raised until it has reached a conisderable height, 
so that the pull comes in hyper ex tension. In spite of the 
fact that the back arches up, this method is fairly efficient in 
removing the deformity in the milder cases, especially in 
recent ones in young children. It is a mat- 
ter of several weeks as a rule. 

Or an apparatus may be used for stretch- 
ing the deformity, which attacks it directly 
and which seems surprisingly efficient in the 
cases in which it has been used. It consists 
of a plaster jacket with a carefully moulded 
pelvic part and a plaster leg. These are 
hinged together opposite the hip joint on the 
affected side, and the hinge is a double one 
reinforced by a truss, as shown in the illus- 
tration. The abduction tendency is so great 
in extension that unless the hinge is very 
strong and protected against abduction the 
iron will be bent as the leg comes down and 
the apparatus thus become ineffective on ac- 
count of the abduction of the extended leg. 
With this hinge, which holds the leg in the 
tail of the hinge seen same pl ane all the way down, it becomes 

from the side. . , . . 

effective upon the contracted tissues in many 
cases of moderate grade and fairly long standing. 

Operation for Hip Flexion. — In former times a very unsat- 
isfactory transverse myotomy was the only means at our 
disposal for the correction of this deformity. It consisted 
simply in a muscular division below the anterior superior spine, 
often going down very deep, even to the division of the psoas 
tendon, and this was followed by prolonged rest in bed with 
hyperextension. The operation was most unsatisfactory, re- 
lapse occurred in the majority of cases, and it was a bloody and 
extensive operation if effectively performed. 

An effective, simple and safe operation has been devised by 
Soutter, 1 which rests on an entirely different basis and which is 
thoroughly efficient even in severe cases. It is sound in 

1 Robert Soutter: "Boston Med. and Surg. Jour.," clxx, No. 2, r _Mar. 12, 1914. 



Fig. 59. — Plaster 
apparatus for stretch- 
ing hip flexion con- 
traction. The small 
figure shows the de 



DEFORMITY AT THE HIP 



87 



principle because it lowers the muscular origin of the tensor 
fasciae femoris instead of dividing its fibers, so that relapse 
seems unlikely and has not occurred in any of the writer's cases 
nor in any case known to him. 

A longitudinal incision two or three inches long is made 
midway between the anterior superior spine of the ilium and the 
trochanter. The tensor fasciae femoris is exposed and divided 
by a transverse incision as far back as the trochanter, reaching 
forward to the anterior superior spine. This opens slightly, 
but does not give much correction. With an osteotome the 





u, e 

Fig. 60. — Fasciotomy for flexion deformity of hip. Soutter's operation, 

(Sautter.) 



periosteum from the anterior superior spine of the ilium is 
loosened, including the cartilaginous tip of the spine, and then 
along the iliac crest both inside and outside of the anterior 
superior spine the periosteum is loosened and stripped down, 
leaving the iliac crest bare. This denuding generally extends 
as far down as the anterior inferior spine. The leg is then 
hyperextended, when all the tissues slip away from the ilium, 
leaving a large space with often a setting down of from one to 
two inches in the origin of the muscle. The wound is closed, 
and the patient put up in a hyperextended plaster spica reaching 
well on to the thorax, and kept recumbent for six weeks. 



88 



TREATMENT OF INFANTILE PARALYSIS 



SCOLIOSIS 

Probably the most troublesome deformity in connection with 
infantile paralysis is lateral curvature of the spine, and its 
treatment has been very imperfectly formulated in literature, 
so that the writer is obliged to rely largely on his personal 
experience. The scoliosis may be evident while the child is 
still lying in bed, and of all the deformities is probably the one 
most frequently overlooked. Naturally the conditions of 
unilateral muscular paralysis which caused it in the first place 




Fig. 6 i. — Severe left dorso lumbar scoliosis from infantile paralysis. 



are going to persist in a measure, and it is not likely to recover 
or to improve spontaneously. It is due to a weakening of the 
muscles on one side of the body, and once weak they are likely 
to remain, so for a long time if not permanently, in contrast with 
those of the other side. 

To attempt to cure the deformity by exercise seems irrational, 
because the basis of the condition lies in a weakness of the 
muscles of one side, and although it may be very well to attempt 
to strengthen these muscles by exercise and is undoubtedly 



SCOLIOSIS 



8 9 



proper, it would be a good while before they recovered power 
sufficiently to hold the spine straight against an oblique super- 
incumbent weight. In the opinion of the writer it is definitely 
desirable in every case of lateral curvature due to infantile 
paralysis to support the spine as early as the deformity is dis- 
covered, even before the children are able to walk. Bone is an 



1 4 
" 131 

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-» 


' 





Fig. 62. — Scoliosis from infantile paralysis probably not associated) with 
shortening in either leg as the gluteal folds are level although the posterior iliac 
spines are marked as uneven. 

adaptive structure and grows in the line of least resistance, and 
to allow a growing child to sit, He or stand in an habitually 
distorted position is to bid for permanent bony deformity. 
This has been established experimentally by Wullstein 1 and 
Arndt. 2 Moreover, the stretching of affected mucles by the 

1 WuUstein: "Zeitsch. f. Orth. Chir.," X, 2. . 

2 Arndt: "Archiv f. Orth. Chir.," i, I, p. 2, : 



9° 



TREATMENT OF INFANTILE PARALYSIS 



deformity is a menace to their improvement or recovery, and 
early cases are often cured by efficient support. 

In the early stages the use of a canvas corset reinforced by 
steels is desirable, even in small children, to prevent the dis- 
torted position of the spine. This is a mild remedy, and im- 
proves the sitting position and in certain early cases cures the 




Fig. 63. — Scoliosis from infantile paralysis associated with shortening of the 

left leg. 



deformity. Later on, when the deformity has become fixed, 
in the writer's opinion there is no alternative but to use mild 
forcible correction. The patient, with the knees flexed, lies 
face downward on a frame, on which run lengthwise two 
webbing straps (Figs. 68 and 69). By means of straps placed as 
shown in the illustration a lateral and unrotating force is exerted 
at the side of the curve, and a plaster-of -Paris jacket is then 



SCOLIOSIS 91 

applied. 1 When the plaster has hardened, a large window is 
cut out over the concave side of the curve and pressure exerted 
on the convex side and on the part rotated backward either by 
pads or by a strap known as the Cook strap, 2 which pulls the 
distorted portion of the prominent part of the spine toward the 
other side and forward. It is surprising what changes can be 
produced in cases of lateral curvature due to infantile paralysis 





Fig. 64. — Scoliosis from infantile Fig. 65. — Scoliosis from infantile 

paralysis before treatment. (See Figs. paralysis after six months' treatment 
66 and 67.) by forcible plaster jackets (same case as 

Fig. 64; z-rays are shown in Figs. 66 

and 67). 

by this method. 3 Following this a removable leather or plas- 
ter jacket may be worn. 

The deformity of lateral curvature in infantile paralysis 
when untreated reaches a very severe and highly troubling 

x Lovett: "Lateral Curvature of the Spine and Round Shoulders," 3d edition, 
Philadelphia, 191 6. 

2 Ansel G. Cook: "The Question of Balance," "Trans. Conn. Med. Soc.," 
1913, p. 113. 

3 Lovett: "Bulletin," Department of Surgery, Harvard Medical School, 
May 20, 1915. 



92 TREATMENT OF INFANTILE PARALYSIS 







Fig. 66. — X-ray of patient shown in Fig. 64. Before treatment. 



SCOLIOSIS 



93 




Fig. 



67. — X-ray of patient shown in Fig. 65 after six months' treatment 
by forcible jackets. 



94 



TREATMENT OF INFANTILE PARALYSIS 



degree, so that it seems useless to wait for this to occur. It is 
better to attack the deformity vigorously and on sound me- 
chanical principles. It is probable that in most moderate and 
severe cases apparatus will have to be worn throughout early 
life and perhaps permanently, and this may consist of braces, 
corsets or jackets of plaster, leather or celluloid, but most cases 
will first require forcible correction as described above. 





Fig. 68. — Patient with rignt dorsal Fig. 69. — Same as Fig. 68 showing 

curve lying in frame preparatory to ap- effect of corrective strap over right 
plication of plaster jacket. - d ^__ thorax. 



DEFORMITY OF THE UPPER EXTREMITIES 

These deformities may occur, but are largely the effects of 
gravity and vary in type. There is one contraction of the 
shoulder which is of considerable practical importance, and 
that is a limitation of the abduction and backward motion of 
the shoulder-joint, which frequently occurs in connection with 
paralysis of the shoulder. This is a handicap to successful 
treatment by muscle training, and can always in the milder 
cases be removed by stretching. 



DEFORMITIES OE THE ARM 95 

In the other joints there is no fixed type of deformity, and 
when it occurs it is generally the result of disturbed muscular 
balance and the force of gravity, the latter being especially 
exemplified in deformities of the wrist occurring in paralysis of 
the arm, where the hand may fall to the ulnar side of the arm 
or into extreme hyperextension, and perhaps become contracted 
in these positions. (Fig. 39.) 



CHAPTER V 
TREATMENT 

OPERATIVE— OPERATIONS TO IMPROVE FUNCTION— TENDON 
TRANSPLANTATION— NERVE TRANSPLANTATION— OPERATIONS 
TO IMPROVE STABILITY— ARTHRODESIS— SUBSTITUTES FOR 
ARTHRODESIS OF THE ANKLE— SILK LIGAMENTS— TENODESIS 
— ASTRAGALECTOMY— TENDON SHORTENING— SUMMARY OF 
OPERATIVE MEASURES 

Aside from the operations intended for the relief of fixed 
deformities which have been described, there are most im- 
portant operations which have for their aim the improvement 
of function. These operations again may be subdivided into 
two classes: (i) those intended to improve existing muscular 
function, and (2) those intended to secure stability. In regard 
to both of these classes of operations it should again be expressly 
stated that they are not to be done within two or three years of 
the acute attack, and that on the whole they are better suited 
to older than to younger cases. Cases under five are hardly 
suitable material for any of these proceedings, because the parts 
are at that time small, a great deal of growth is to occur, and 
post-operative distortion is much more likely to take place than 
when older cases are operated on. There is no definite rule to be 
laid down in this matter but on the whole the class of operations 
to be described is more satisfactory when performed at or after 
middle childhood. 

I. OPERATIONS INTENDED TO IMPROVE EXISTING MUSCULAR 

FUNCTION 1 

Tendon Transplantation. — This operation is of much im- 
portance, and under proper conditions is one of the most bril- 
liant operative proceedings in orthopedic surgery. Although 
the transposition of tendons was performed as early as 1770 by 
Nissa 1 in a traumatic case, and at various subsequent times 

1 Nissa: "Gaz. Salut," 1770, 2. 
Vulpius: "Sehnenueberpflanzung," Leipzig, 1902. 

96 



TENDON TRANSPLANTATION 97 

tendon anastomosis was performed for similar conditions, it 
was first done in infantile paralysis by Nicoladonai, in 1880. 1 
After its first description and after many modifications and 
much question as to its usefulness, the operation has reached 
a stable position where it is recognized as a useful, safe and 
brilliant operation if done under proper restrictions. 

In theory it consists in the substitution of a healthy, non- 
paralyzed muscle for one which has lost power. For example, 
if the anterior tibial muscle is paralyzed, the foot falls into a 
position of valgus and eversion, and when dorsal flexion is 
attempted the foot is flexed in a position of abduction and 
eversion, the anterior tibial not holding it over to the inner 
side of the leg in this motion. A serious and disabling deformity 
thus starts, which in a growing child is likely to get steadily 
worse. Retention of such a foot in a brace is difficult to ac- 
complish mechanically, and means that a brace must always be 
worn, whereas if the peroneal muscles are left unparalyzed 
one of these may easily be substituted for the anterior tibial. 
It makes no difference to a muscle where it is inserted for it pays 
but little attention to a change of its distal end. It is therefore 
possible to rebalance a foot by this proceeding. Every case 
represents a separate anatomical problem, and there are certain 
general rules regarding the operation which it is well to bear in 
mind. 2 It must be remembered however that a tendon trans- 
plantation cannot be done unless there are at hand fairly 
normal muscles to transplant. The question does not arise in 
a wholly paralyzed region. 

Insertion. — Originally the transplanted tendon was sewed to 
the tendon for which it was to be substituted, 3 but this method 
has been on the whole less satisfactory than the insertion into 
the periosteum, as advocated by Lange, 4 and the periosteal 
insertion now prevails. Another distinct modification of the 
operation has been brought about by the discovery that when 

1 Nicoladonai : "Wien Med. Presse," 1881, s. 46. 
2 Bucceri: "Arch, di Ortop.," 1909, 2. 

Kirschmer : "Beitr. zur Klin. Chir.," 65, p. 472. 
3 Vulpius: "Behand d. Spin. Kinderlahmung," Leipzig, 1910. 
4 Lange: "Ergeb. d. Chir. u Orth.," Bd. II, Berlin, 191 1. 

Lange: "Zeitsch. f. Orth. Chir./ Bd. XVII, p. 266 and Bd. XXX. 
7 



98 TREATMENT OF INFANTILE PARALYSIS 

a muscle is too short to reach to its destined insertion it can be 
prolonged by silk, which is inserted in place of the tendon as a 
prolongation of it, and this silk becomes surrounded by fibrous 
tissue, making a perfectly good tendon. This technique as 
worked out by Lange 1 has increased greatly the efficiency and 
applicability of the operation, and it is now extensively used. 

In transplanting a tendon, therefore, there are three methods 
which may be pursued: (1) The tendon may be sewed into 
another tendon, as advocated by Vulpius; 2 (2) the tendon itself 
may be sewed into a slit in the periosteum; or (3) the tendon 

may be prolonged by silk 



n^sssssss 55s^-.--g3^:::Bggg>.= ::g and the distal end of the 
n^„^» TBTr ^ i/-: : gsg»-.: -.ami'=- s ^ sewed into periosteum, 

Fig. 7 o.-Silk extension of tendon. 0r P aSSed thr0U S h a hole 

drilled in the bone. In a 
questionnaire 3 addressed to the members of the American 
Orthopedic Association in 19 10, twenty-eight used periosteal 
implantation, five used tendon to tendon suture, and five used 
both methods. 

In the writer's experience the following general considera- 
tions are of great importance in securing satisfactory results 
after tendon transplantation: 

1. Operative cases should be selected with care, and only 
those chosen in which it is perfectly clear that improvement is 
to be expected from the operation. 4 It is of doubtful utility 
to substitute such a muscle as one of the peronii for the gastroc- 
nemius, because it cannot possibly hypertrophy to the extent 
of supporting the body-weight, and in general it is not wise to 
change flexors for extensors, as well coordinated function as a 
rule does not follow such operations. 

2. Existing fixed deformity must be removed before tendon 
transplantation. 

1 Lange: "Weiter Erfahrungen uber Seidene Sehnen." "Munch. Med. 
Wchsft.," No. 1, 1902. "Zeitsch. f. Orth. Chir.," XXIX. "Zeitsch. f. artz 
Fortbildung," 1905, No. 22. 

2 Vuipius: "Deutsch. Med. Wchsft.," 1912, No. 36. 

3 Lovett: "The Treatment of Paralytic Deformity," Int. Med. Congress, 
Budapest, "Boston Med. and Surg. Jour.," April 14, 1910. 

4 Robert Jones: "Brit. Med. Jour.," 1911, p. 1520; "Clin. Jour.," London, 
May 13, 1914. 



TENDON TRANSPLANTATION 99 

3. Tendons should be inserted into periosteum either by 
being sewed there themselves or by means of silk extension. 
Tendons transferred should be passed subcutaneously, and it 
is essential that the transferred tendon should approach its. 
insertion in the line of the tendon for which it is substituted. 
The passage of the tendon in the sheath of the replaced tendon 
as advised by Biesalski 1 has not been found necessary by the 
author. 

4. Transferred tendons should be attached with moderate 
tightness so that when the limb is in the over-corrected position 
there should be moderate tension on the transferred tendon. 
From our best knowledge at present the period of fixation in the 
over-corrected position should be at least three months, after 
which a removable fixation plaster or supporting brace should 
be worn until a year after operation to hold the member some- 
what overcorrected to prevent strain from coming on the 
transferred tendons. From the time that the fixation plaster is 
removed, massage and muscle training of the transferred muscles 
should be followed out. 

5. There are two dangers to be remembered in the after 
results: (i) insufficient correction, and (2) over-correction, the 
former being the more frequent. At the same time a very 
bad valgus may result from the taking away of the anterior 
tibial from the inner side of the foot and transferring it into the 
outer border. In this operation objectionable over-correction 
is more likely to result than in any other operation, although 
the transfer of both peroneals to the inner side of the foot may 
result in an objectionable varus. 

6. In the matter of technique, it must be evident that where 
masses of silk are to be left in the subcutaneous tissue after a 
long dissecting operation the strictest asepsis is required. 
Fingers should never be put into the wound, the silk should be 
handled by forceps, and in every respect the most rigid asepsis 
should be maintained from the beginning of the operation until 
the end. Under these conditions drainage is not necessary. 
The operations are performed with the use of the Esmarch 
bandage. 

1 "Deutsch. Med. Wchsft.," 1910, No. 35. 



IOO TREATMENT OP INFANTILE PARALYSIS 

Preparation of Silk. — As to the preparation of silk, this 
has gone through many modifications, at one time silk prepared 
in paraffin being almost exclusively used. After a trial of all 
methods the writer has settled down to a perfectly simple 
method, which has given more satisfaction than any other 
one used, by its simplicity, its efficiency and its failure to 
irritate the tissues. Common twisted silk, sizes 16 and 18, is 
used for silk extensions, and is boiled for half an hour in i : iooo 
solution of corrosive sublimate. It is then taken from this and 
boiled with the instruments immediately before the operation, 
and used in a sterile towel. This preparation has given rise 
to less irritation from the silk than any other method including 
paraffin silk, plain boiled silk, and silk boiled in oxycyanide of 
mercury. 

Operative Plan. — There is no definite rule to be laid down 
as to which are and which are not available operations. In 
the earlier operations there was a tendency toward great 
complexity, splitting of tendons, doing many things at once 
and a generally intricate plan. The later operative tendency 
among the most experienced surgeons is toward simpler 
operations, attempting to do fewer things at a time, and to do 
things that are obviously of anatomical benefit and which 
are mechanically sound. The most frequently performed and 
the most available operations are the following: 

Foot. — In a dropped foot the anterior tibial and larger ex- 
tensors may be paralyzed, but the extensor of the great toe 
may be active and contribute toward the dorsal flexion of the 
foot by its action. It can only do this, however, after it has 
hyperextended the toe. This muscle will work to better 
advantage if it is given an insertion into the inner side of the 
tarsus, preferably anterior to the scaphoid bone. Although 
it is not a powerful muscle it will aid in preserving the balance 
of the foot, and at times helps the efficiency of the foot by 
increasing the power of dorsal flexion. 

In cases of varus where the peroneal muscles are paralyzed, 
the anterior tibial muscle should be cut off just above its 
insertion, freed to the junction of the lower and middle third 
of the leg, and then passed down subcutaneously to a point a 



TENDON TRANSPLANTATION 



IOI 



little to the outside of the middle of the dorsum of the foot and 
given a periosteal insertion at about the level of the medio- 
tarsal joint. It is not wise to make this insertion much out- 






Fig. 71. — Tendon transplantation Fig. 72. — Tendon transplantation an- 
extensor of great toe inserted with terior tibial to outer side of foot, 

tarsus. 





Fig. 73. — Tendon transplantation peroneus longus to inner side of foot. 

side of the third metatarsal bone, for the reason that the foot 
may become overbalanced and a serious valgus result. 

In cases of talipes valgus resulting from paralysis of the an- 



102 TREATMENT OF INFANTILE PARALYSIS 

terior tibial, if the peroneals are good, one of the peroneals 
may be transplanted to support the inner side of the foot, and 
this is one of the most brilliant of the tendon transplantations. 
It is dangerous to transplant both peroneals, and if one is used 
it must not be put too far in on the foot. It does not matter 
which is taken, but the peroneus longus is generally used. A 
long incision is made, and one of the peroneals divided near 
its insertion. The muscle then is cleared nearly to the middle 
of the leg and then subcutaneously passed directly inward 
transversely to an opening made over the crest of the tibia. 
It is pulled out through this, and from this passed down to the 
inner side of the foot, where it is inserted in the usual way. 
In this operation a silk extension of the tendon is necessary, 
as the tendon will not reach to the new insertion. It is better 
to sew up the empty sheath of the transferred tendon, as it 
has happened in cases of the author's that what appears to be 
an active- tendon has developed in such sheaths. In one case 
both peronei were transferred to the inner side of the foot. 
The sheath was carefully sewed up, and some years afterward 
a functioning tendon was found at the site of the peroneal 
muscles. The object of passing the tendon transversely across 
at the middle of the leg is to bring the transferred tendon 
down to its insertion in the line of the tendon which it is to 
replace. A tenotomy of the tendo Achillis in connection with 
this operation should be performed with great, reserve because 
a calcaneus frequently follows such a procedure. When 
absolutely necessary an open plastic tenotomy should be done 
to prevent indefinite lengthening of the tendo Achillis. 

When the tibialis posticus muscle alone is paralyzed, a valgus 
position results, and for the paralyzed muscle may be sub- 
stituted the flexor hallucis or the tendon of the peroneus longus 
brought around under the tendo achillis and sewed to the 
periosteum at the inner side of the foot. 

Talipes calcaneus is a condition not in the writer's opin- 
ion likely to be benefited by muscle transplantation. The 
peronei or posterior tibial may be substituted for the gastroc- 
nemius but they have in the writer's experience never been 
strong enough for good function and such operations have 
uniformly been unsatisfactory. 




TENDON TRANSPLANTATION IO3 

Hamstring Transplantation. — This operation is frequently 
performed at the knee, one or two hamstring muscles being 
carried forward and inserted by silk extension into the tuber- 
cle of the tibia. At least one good hamstring must be left 
in place at the back of the knee to serve as a flexor of the knee 
and the operation should not be performed unless the gastroc- 
nemius is good, because that also is a knee flexor. Although 
the operation is often successful in improving quadriceps 
function, it occasionally fails to secure active ex- 
tension movement although the knee may be 
stable for weight bearing and is most likely to be 
successful if the quadriceps possesses some power, 
being not wholly paralyzed. Prolonged fixation 
is required before weight is allowed to come upon 
the knee. 

The theoretical difficulty about the ultimate 
result of the operation is that flexors never work ^ Fl , G - 74 * 

^ , m Tendon trans- 

al together well as extensors, and although in time plantation, 
the patient may be trained to extend the knee ul- f rward. r * n S S 
timate function is sometimes unsatisfactory. 

At the hip, satisfactory tendon transplantations are rare. 
Lange has substituted the vastus externus for the paralyzed 
gluteus medius and minimus. The upper attachment of the 
vastus is detached from the trochanter major, and by a series 
of silk attachments sewed to the crest of the ilium, aiding the 
abduction power to the leg. 1 

The sartorius was substituted 2 for the quadriceps muscle in 
earlier operations, but it is a small muscle and is not likely to 
prove a satisfactory substitute. 

Other Transplantations. — In the arm, at the shoulder the 
trapezius has been frequently transplanted to substitute for 
the deltoid, 3 but in nearly all cases this results in failure, and 

1 Lange: "Am. Jour, of Orth. Surg.," August, 1910, p. 19. 

2 Goldthwait: "Boston Med. and Surg. Jour.," 1897, No.. 20. 

3 Bradford: "Am. Jour, of Orth. Surg.," VIII, p. 21. 
Killiani: "Annals of Surgery," January, 1910. 
Katzenstein: "Berlin Kl. Wchsft.," Dec. 6, 1909. 
Lewis: "Jour. A. M. A.," Dec. 14, 1910. 

Spitzy: Zeitsch. f. Orth. Chir., xxx, Beilage Heft, p. 221. 



104 TREATMENT OF INFANTILE PARALYSIS 

although occasional cases succeed, the operation is on the 
whole unsatisfactory and not to be recommended. There is, 
however, an operation that is fairly successful in substituting 
for the deltoid the pectoralis major muscle. A long incision 
is made comprising the sternal and half of the clavicular origin 
of the muscle and reaching over the shoulder to the spine 
of the scapula. The sternal and clavicular parts are then 
detached from the chest as high up as is safe without impairing 
the nerve supply, and this portion of the muscle is then slung 
over the shoulder and sewed into the spine of the scapula 
subperiosteally (Legg's technique). The arm is then done up 
in a position of abduction on a level with the shoulder, and re- 
tained in this position for several months. Excellent results 
have been in many cases obtained from this method (Hilde- 
brand, Sachs, Sam ter, Lange, Legg). 

In the arm, tendon transplantation has not on the whole been 
nearly as satisfactory as in the leg. When need for tendon 
transplantation in the arm does arise it is generally perfectly 
clear, but there is no one type of operation in general use, and 
each case must be worked out on general anatomical principles. 

In the leg in certain cases it is desirable to combine tendon 
transplantation with tendon fixation, astragalectomy or silk 
ligaments, which serve as reinforcements. Tendon transplan- 
tation is applicable to both adults and children at or after 
middle childhood. 

After-treatment. — The after-treatment of muscle transplan- 
tation has been already spoken of, and in this place it is only 
necessary to repeat the fact that prolonged after-treatment is 
one of the essentials to success. Fixation should be persisted 
in for from three to six months, according to the weight to be 
borne on the member when use is resumed, and at least six 
months more in a rigid plaster or metal splint. After a few 
months, massage and muscle training should be begun, and 
should be continued until the limb is ready for unprotected use, 
which will not be until a year after the operation. 

Of course, in many cases massage and muscle training are not 
available, but a better result as a rule is obtained when they are 
used. When weight is borne, a year from the time of operation, 






NERVE TRANSPLANTATION 105 

the mechanical conditions should be made favorable. For 
instance, when the foot was originally in valgus it is wise when 
weight is first borne to tip it to the outer side by raising 
the inner side of the heel or of both heel and sole, to take the 
strain off of the inside, and vice versa for the deformity of 
varus. 

In the opinion of the writer it is not sound surgery when 
the thigh is paralyzed in such a way that weight cannot be 
borne upon the leg in walking to do tendon transplantation or 
other radical operations in the ankle except to correct deform- 
ity. Muscle transplantation is an operation requiring a long 
disuse of the leg, and when the upper leg is useless for walk- 
ing purposes there is no need of attempting to give greater 
power to the foot, because it could not be used for unaided 
walking on account of the condition in the upper leg, and 
some form of brace would be necessary anyway. 

NERVE TRANSPLANTATION 

The anastomosis or transplantation of nerves whereby an 
unaffected nerve is attached to one whose function has dis- 
appeared is a proceeding which is physiologically sound and 
which can be demonstrated experimentally in animals as effi- 
cient. But in the case of patients although successes are re- 
ported, on the whole the operation has not as yet been widely 
performed. Spitzy and Stoeffel have perhaps contributed 
more to the present knowledge and technique than have the 
various others whose names have been connected with the 
operation (Bethe, Hackenbruch, Kilvington, Kennedy, Tubby, 
Zeiss, Bardenhauer). 

The sound peripheral nerve may be transplanted into the 
affected one either peripherally or distally, the insertion may 
be central or peripheral, the whole or part of the nerve may 
be used. Spitzy advises that the operation be performed 
before there is too great degeneration of the affected nerve ends 
in the muscle. 

"If the life of the muscle deteriorates for months, the nerve plastic 
should then be undertaken, for a spontaneous regeneration must show 



106 TREATMENT OF INFANTILE PARALYSIS 

itself in the course of the first six months either by a little twitching in the 
muscle or by an increase or at least stationary condition of the quantity 
and quality of the electrical irritability." 

If successful, power may be expected to begin to return from 
the third week onward, the return of voluntary action generally 
preceding that of electrical. 

The results claimed by Spitzy in 1911 1 were not particularly 
encouraging because he of all operators had probably the largest 
experience in the experimental and clinical development of 
nerve transplantation. His results were in sixty-one operations 
30 per cent, good, 40 per cent, not entirely satisfactory, and 
30 per cent. bad. In the hands of a less skillful person the 
percentage of success would probably be far lower. Again the 
necessity of early performance is in a way an obstacle to the 
general acceptance of the operation because it has been recently- 
shown 2 that the possibility of the late return of power is greater 
than formerly supposed and this is opposed to operative 
procedures until this possibility is gone. 

Routine examples of nerve plastics are the following: In 
paralysis of the hip a branch of the obturator nerve is trans- 
planted into the anterior crural. For relief of paralysis of the 
quadriceps the paralyzed crural nerve is transplanted into the 
sciatic. In another case a branch of the sound crural nerve 
was carried through a tunnel in the symphysis pubis and trans- 
planted into the paralyzed nerve on the other side of the body 
(Borgle and Maragliano). The peroneal nerve may be used to 
innervate the tibial and the tibial nerve, the peroneal, etc. The 
literature of the subject of nerve transplantation is quoted 
rather fully in order that one may consult the original sources 
from which the preceding facts have been collected. 3 

1 Spitzy: "Handbuch d. Kinderheilk," Lange and Spitzy, Leipzig, 1910, 
p. 310. "jahrbuch far Orth. Chir.," 1911, Berlin, p. 45. 
2 Lovett and Martin: "Jour. A. M. A.," Mar. 4, 1916. 
3 Osgood: "Review," "Boston Med. and Surg. Jour.," June 30, 1910. 

Duroux: "Lyon Chir," December, 191 2. 

Zeiss: "Boston Med. and Surg. Jour.," May 11, 1911. 

Stoeffel: "Munch Med. Wchsft.," 1910, 5. 

Spitzy: "Zeitsch. f. Orth. Chir.," Bd. xiii. 

Bardenhauer: "Arch. f. Klin. Chir.," Bd. 89, Hft. 4. 



NEUROTIZATION OF MUSCLES 107 

Kilvington: "Brit. Med. Jour.," April, 1907. 

Vernicchi: "Arch. di. Ortop.," 1910, xxvii, p. t>2>7- "Ref. Zentblt. f. Orth. 
Chir.," xxvii, 546. 

Neurotization of Muscles. — It has been shown experiment- 
ally by Erlacher 1 and Steindler, 2 if a muscle is artificially par- 
alyzed by nerve section and the peripheral end of a healthy nerve 
is implanted into the paralyzed muscle that in a few weeks 
electrical nerve impulses may be sent down the transplanted 
nerve and cause a contraction of the muscle in which it is im- 
planted. The method may later be applicable in infantile 
paralysis but at present the method is wholly in the experi- 
mental stage and is not ready for clinical application. 

II. OPERATIONS TO SECURE BETTER STABILITY 

The operation of muscle transplantation aims at giving 
better function in the affected member by substitution of the 
tendon of a healthy muscle for that of a paralyzed one. In 
many cases there are no active muscles to transplant, all the 
muscles of the region being paralyzed. At the ankle, for in- 
stance, there is often a flail-joint, which is unstable in walking 
and which does not clear the ground on account of the toe- 
drop when the foot is off of the ground. Under these conditions 
a stable joint, especially an ankle which is checked from 
dropping, is more useful than a flail-joint, and numerous 
operations have been proposed for the stiffening of the ankle 
and other joints, thus securing greater stability. 

Arthrodesis. — An artificial ankylosis thus named produced 
by the removal of the articular cartilage has been in extensive 
use, particularly at the ankle-joint. It was named by Albert 
who was the first to operate on a series of cases at the ankle- 
joint, which he reported in 1882. With the better development 
of the operative side of orthopedic surgery the operation of 
arthrodesis at the ankle is less often performed than was 
formerly the case because better functional results are to be 
obtained by other operations. The joint is opened, preferably 
by an anterior incision, the cartilage removed by a chisel or 

1 "Am. Jour, of Orth. Surg.," 1915, vol. xiii, p. 22. 

2 "Am. Jour, of Orth. Surg.," 1915, vol. xiii, p. 33. ' 



108 TREATMENT OF INFANTILE PARALYSIS 

osteotome from the top of the astragalus and the lower surface 
of the tibia and the foot being placed carefully at a right angle 
to the leg with no inversion or eversion, a plaster is applied 
and the ankle-joint is fixed for a period of some three months 
at least, in order to secure firm ankylosis. Many operators 
also stiffen the mediotarsal joint by removing the cartilage 
from that also to prevent a drop of the forefoot which often 
happens and if one performs arthrodesis of the ankle it is 
desirable to stiffen both joints. 

There are definite objections to the operation. 1 First, it 
causes a stiff ankle which is a handicap in walking and causes 
some limp because it does not allow dorsal flexion of the foot. 
And, second, if young children are operated on, in a certain 
number of cases the result will be a distorted foot, generally 
twisted into the position of varus. A third objection often 
made is that firm ankylosis may not occur at the operated 
joint. 

Although it would seem that a sufficiently destructive 
removal of joint surfaces would surely result in ankylosis the 
fact remains that skillful and experienced surgeons will oc- 
casionally fail to secure a stiff joint. The greatest safety 
lies in waiting until the bones are sufficiently ossified to allow 
bony surfaces to be exposed and then after a sufficiently 
radical operation to place in accurate apposition raw bony 
surfaces. 

In the writer's opinion arthrodesis of the ankle is an opera- 
tion yielding at the best an imperfect functional result and 
although often desirable in adults it seems dangerous in young 
children and less desirable in older children than the measures 
to be described. 

Arthrodesis of the knee is not an operation to be lightly 
undertaken, because in children to shave off enough cartilage 
to secure ankylosis may change or injure the epiphyseal lines 
and very seriously interfere with the growth of the leg which 
takes place largely at the knee epiphyses. At best, even in 
adults, it furnishes a stiff knee which cannot be bent, and a stiff 
knee is awkward and unhandy, so that most people prefer to 

x Laau Nederlandsch Tijd. v. Geneeskunde II., No. 16, p. 1347. 



ARTHRODESIS IO9 

wear a brace. This operation at the knee, therefore, in the 
opinion of the writer should not be encouraged. 

Arthrodesis of the hip is not a very satisfactory operation, 
because often one fails to secure bony ankylosis. When the 
operation is performed nothing short of a complete denuding of 
the head of the femur and of the acetabulum is likely to serve. 
The Hoffa-Lorenz incision is used, the capsule opened and the 
cartilage thoroughly removed from both surfaces. The leg is 
then put up in a plaster-of-Paris spica in slight abduction. 

In the arm, arthrodesis of the shoulder is a useful operation 
where there is complete paralysis of the shoulder and where 
no muscle transplantation is possible. The arthrodesis is 
done through an anterior incision and the arm fixed in a 
position of slight abduction from the side. If ankylosis occurs 
very useful function will result, because by scapular movements 
it is possible to raise the arm to a horizontal position. It is 
probable that, in addition to the arthrodesis, fastening the 
humerus to the acromion by heavy silk strands makes the 
operation more likely to succeed. 

Arthrodesis of the elbow to secure a right-angled joint in 
cases of complete paralysis of the arm would be perfectly 
useful were it not that in these cases as a rule the hand is also 
paralyzed, and a right-angled elbow with a dangling hand is 
not a very useful arm. It is an admirable operation when 
conditions are favorable. 

Substitutes for Arthrodesis of the Ankle. — Other operations 
as additions to, modifications of, or substitutes for arthrodesis 
are the following: 

1. Hojfa. 1 — All the extensors en masse were gathered up 
with a hook and shortened by means of making a loop. Relapse 
followed as a rule from stretching. 

2. Vulpius 2 (Fasciodesis) . — The extensor tendons are sewed 
to the fascia over the skin. Later the operation was combined 
with arthrodesis. Alone it was unsuccessful. 

3. Cramer 3 lays a periosteal flap over the anterior surface 
of the joint. 

1 Hoffa: "Orthop. Chir.," 5th edition, Stuttgart, 1905. 

2 Vulpius: "Zentralbl. f. Orth. Chir.," 1907, p. 97. 

3 Cramer: "Zentralbl. f. Orth. Chir./' 1910, p. 113. 



IIO TREATMENT OF INFANTILE PARALYSIS 

4. Codivilla 1 performed an arthrodesis of the ankle-joint 
and then fastened a part of the tendo achillis to the dorsum 
of the foot and sutured the tendon of the peroneus brevis 
drawn from the sole of the foot to the bones of the leg and 
shortened the anterior tendons. 

5. Lexer 2 drove a bone peg from the sole of the foot through 
the tarsus into the bottom of the tibia and Bade used an ivory 
peg in the same way. The bone peg is usually absorbed in 
about one year, after which motion generally returns. 

6. J ones. 3 — In cases of paralytic equino-valgus where inver- 
sion of the ankle is not possible on account of contractions an 
arthrodesis is performed at the ankle. A wedge, three-fourths 
of the diameter of the bone, is removed from the tibia and the 
fibula is also divided. The foot is then put up in the position 
of eversion for two weeks when the bones where partly divided 
are fractured and the foot put up in proper relation to the leg. ■ 

7. Jones. 4 — In paralytic calcaneo-cavus an operation devised 
by Jones is performed in two stages. First, a narrow tarsal 
wedge with base upward is removed quite across the foot, the 
cavus corrected and the foot bandaged to the tibia in extreme 
dorsal flexion. After a month in this position an arthrodesis 
is done at the ankle and at the same time a wedge is removed 
from the astragulus. The foot is then fixed at a right angle. 

8. Transverse Section of the Foot. — Davis 5 has described an 
operation for calcaneus and calcaneo-cavus deformity which, 
although complicated and somewhat difficult in its performance, 
is attended by excellent functional results. The technique is 
as follows: 

"An incision is made on the outer side of the foot about two inches 
long, extending from the posterior edge of the external malleolus forward; 
it lies close to its tip. The long and short peroneal tendons then come 
into view and if it is desired to transplant them into the os calcis they are 
cut long and turned out of the way. If it is desired to preserve them 

1 "Zeitsch. f. Orth. Chir.," Bd. xii, p. 221. 

2 "Archiv f. Klin. Chir.," Bd. xcviii, Hft. 3. 

3 Robert Jones: "Report on Arthrodesis," xvi, Int. Cong, of Surg., September, 
1909. 

4 Robert Jones: "Am. Jour. Orth. Surg.," April, 1908. 

5 "Am. Jour. Orth. Surg.," October, 1913, p. 240. 



ARTHRODESIS III 

intact, they can be loosened from their sheaths and held aside. Through 
this incision, with a chisel and periosteal elevator, the soft structures are 
raised from the bones anteriorly and posteriorly. Then a transverse 
horizontal section of the bone is made in the line of the skin incision, but 
passing entirely through the tarsus from the junction of the os calcis and 
astragalus posteriorly and emerging on the anterior surface of the cunei- 
form bones. In making this bone section no attention is to be paid to. 
the joints. It passes through the subastragaloid joint cutting off parts 
of the upper portion of the os calcis and lower portion of the astragalus; 
it may clip off a piece of the upper portion of the cuboid, the scaphoid 
and the upper portion of the cuneiform bones. These pieces may or may 
not be removed. As it is too difficult to loosen the foot sufficiently through 
this incision another about one inch long is made on the inner side of the 
foot below the internal malleolus and over the sustentaculum tali. The 
tendon of the tibialis posterior is exposed and loosened from its sheath 
and held out of the way. The soft parts having been loosened from the 
bones anteriorly and posteriorly the bone section is completed from the 
inner side. An effort is then to be made to push the foot back and the 
leg forward. If this cannot be done then with a chisel or other instru- 
ment the soft parts are loosened still more until the foot can be displaced 
as far backward as is desired. Any loose pieces of cartilage or bone that 
may be present in the incision can be removed. If desired, the peroneal 
tendons can now be implanted into the os calcis, the external incision 
being prolonged backward or a posterior incision added if necessary. 
To hold the foot in its new position chromic gut sutures may be passed 
from the tibia and fibula above to the tarsal bones below. The wounds 
are to be closed without drainage, and the foot put up in plaster of Paris. 
A wooden sole plate is to be incorporated with the plaster and it is to be 
placed in a position of slight varus and equinus. While the plaster is 
setting, the foot is to be pressed firmly back and the leg bones forward 
as much as possible. If desired, at the end of a week or so, a window 
may be cut in the plaster and the wound inspected, or the plaster and 
dressing may be entirely renewed and this left on until eight weeks have 
elapsed. The plaster cast is then removed and a simple ankle brace 
substituted to keep the foot from everting under pressure. This may be 
worn for a few months until bony consolidation is complete, to be followed 
by a suitable shoe." 

g.' Biesalski 1 makes a transverse incision over the dorsum 
of the foot, divides the extensor and tibial tendons higher up 
and turns them back and does an arthrodesis of the ankle- 
joint and mediotarsal joints. A hole is then bored in the tibia 

1 Biesalski: Lange's "Lehrbuch der Orthopadie," Jena, 1914, article "Nerven 
krankheiten." 




112 TREATMENT OE INFANTILE PARALYSIS 

running longitudinally up and forward. The divided tendons 
are drawn through this hole and fastened to the fascia and 
periosteum of the tibia. Sometimes such strands also are 
passed from the insertion of the tendo achillis 
to the posterior surface of the tibia. 
10. Silk ligaments. 
ii. Tenodesis. 
12. Astragalectomy. 

The three latter, an account of their more 
general use, will receive more extended con- 
sideration. 

tton'shol&SS; SILK LIGAMENTS' 

US e. ~ The use of silk to extend tendons and re- 

inforce joints by forming artificial ligaments 
depends upon its property of becoming surrounded by fibrous 
tissue. This was brought to the notice of the profession by 
Lange 2 although the original use of silk ligaments was credited 
by him to Herz. 3 

The operation possesses the advantage, in cases of foot-drop, 
of allowing dorsal flexion but preventing foot-drop. The 
operation has in the writer's hands proved on the whole useful 
in properly selected cases and the following figures were col- 
lected from an analysis of cases. It has the advantage of not 
interfering with the muscles of the ankle-joint, so that if there 
is |a return of power in partly paralyzed anterior muscles fol- 
lowing the relief of their stretched position the power to dorsally 
flex the foot may return. The disadvantages of the operation 
are that the silk sometimes breaks probably because too few 
strands are, as a rule, used, that care is required in correcting 
the balance of the foot to one side or the other, and that knots 
in the silk if left below the level of the boot may chafe through. 
These defects are partly remediable but the operation at times, 
in spite of all precautions, fails. In the use of silk ligaments 
at the ankle three different techniques are used: 

^ovett: "Am. Jour. Orth. Surg.," January, 1915. 

2 Lange: "Munch. Med. Wchrft.," 1907, 17. "Zeitsch. f. Orth. Chir.," 
xvii, 266. 

3 Herz: "Munch. Med. Wchrft," 1906, 51. 



SILK LIGAMENTS II3 

(a) Periosteal Insertion. — An incision is made over the crest 
of the tibia, the periosteum turned back and silk quilted up one 
side of the reflected periosteum and down the other, and four 
or more strands then carried down under the annular ligament 
by means of a long flat probe with a large eye to an incision 
made in the tarsus, where it is desired to attach the silk. Here 
it is again quilted into periosteum. The insertion may be at 
the inner or outer side of the foot or at both or at the middle, 
and all strands passed to the desired spot and fastened there. 

(b) The Open-bone Method. — The tibia is cut down on, the 
periosteum turned back, and a bone drill with an eye driven 
through the tibia from side to side. Into the eye of the drill 
is then passed a loop of silkworm-gut, the two ends of which 
are drawn through the hole, while the loop remains on the other 
side and the drill is disengaged and the leader left in place. 
The point on the foot is then selected for the tarsal insertion 
and cut down on and drilled in the same way and by means of 
a leader of silkworm-gut silk is drawn through the tarsal hole 
in the bone. If the foot is large, two double strands of silk 
about No. 12 should pass through the hole, and eight 
strands would then be carried up to the tibia. If larger silk 
(No. 18) is used, fewer strands are needed than with No. 12. 
Strands may pass to both inner and outer sides of the foot from 
the same hole in the tibia if desirable for stability. From the 
tibial incision is then passed down the probe, the silk passed 
through the hole in the tarsus is then put through the eye, and 
passing under the annular ligament is brought out of the tibial 
incision. Half of the silk thus brought up is then passed 
through the loop of the silkworm-gut leader, which was left 
in the drill hole in the tibia, and drawn through, the foot is 
placed in the desired position and the silk tied, the knot being 
located at the outer side of the tibia between it and the fibula. 
In this way no knot is left for pressure in the foot from the boot. 

(c) Subcutaneous Bone Method. — In this method a drill 
with an eye is driven directly through the skin without an in- 
cision at the desired location in the foot, and by means of a 
leader of silkworm-gut the silk is then carried through the drill 
hole. The tibia is then drilled in the same way without an 



114 TREATMENT OF INEANTILE PARALYSIS 

incision, and through the drill hole in the tibia, enlarged slightly 
if necessary, a stiff flat probe with an eye is passed down and 
out through one of the drill holes in the tarsus, the silk passed 
through it and drawn back and out of the upper hole. The 
same proceeding is repeated for the other drill hole in the tarsus. 
The silk strands are then drawn through the hole in the tibia by 
a leader, and the drill hole opening where the strands emerge is 
enlarged sufficiently to allow a deep knot to be tied. 

Choice of Methods. — The preference of the writer is for the 
open-bone drill method. Periosteum is often thin and tears 
easily. It has been found in some cases that the silk not only 
tore out of the periosteum, but in other cases pulled away the 
periosteum from the bone in a long nipple-shaped process, and 
the analysis which follows shows that the proportion of good 
results from the bone operation is larger than that from the 
periosteal. 

The open-bone operation seems better than the subcutaneous 
because it seems likely to stir up more periosteal activity at the 
site of the drill holes, which would result in the deposit at these 
places of bone from the stripped up and displaced periosteum. 

In estimating the usefulness of the operation it is necessary 
to consider the really ultimate results, that is, the results a year 
or more after operation. It is often the case that six months 
after operation the result apparently is perfect, but after 
some months more, when all apparatus has been removed, the 
result proves to have been unsuccessful, and a relapse into the 
original condition occurs. 

As personal impressions are likely to be misleading, and 
as the operation is not regarded with favor by many excellent 
operators, the attempt has been made to see what the results 
really were in 19 14 in the cases operated on at the Children's 
Hospital, Boston, in the years 1 907-1 913 inclusive. The 
seventy-nine operations analyzed were performed by the dif- 
ferent members of the staff, and represent the work of six 
operators. The conditions under which the operations were 
done were much the same for all, £0 far as operating conditions 
were concerned, but the technique varied among different 
operators. 






SILK LIGAMENTS 115 

Analysis of Results. — Of seventy-nine operations on sixty- 
eight patients, fifty-one were periosteal insertions and twenty 
bone, while in eight it was not stated whether the bone or 
periosteal method was used. Results were classified as suc- 
cessful when the desired result was obtained and the foot held 
at a right angle, partially successful when the condition was 
improved by operation but when there was some dropping of 
the foot. The term failure shows no perceptible improvement 
from the operation, but it is of interest to note that in no case 
was the condition made worse by it. 

Of forty-four periosteal operations where the result could be 
verified : 

30 per cent. (13 cases) were successful. 

20 per cent. ( 9 cases) were partially successful. 

50 per cent. (22 cases) were failures. 

Of seventeen bone drill operations where the result could be 
verified : 

70 per cent. (12 cases) were successful. 

12 per cent. ( 2 cases) were partially successful. 

17 per cent. ( 3 cases) were failures. 

Where an external ligament has alone been required the fibula 
has been used instead of the tibia for its upper insertion, put- 
ting it through the fifth metatarsal or cuboid below. For an 
internal ligament the silk has been run from the tibia to the 
scaphoid or cuneiform. 

In tying the knot the foot should be fully at a right angle 
with the leg, as in no case has the writer seen any over-correction 
from growth. It has been stated that while the leg grew the 
silk did not, and that deformity would come as a result. In 
no case in the series has there been any suggestion of this, nor 
has any evidence been seen of over-correction in any direction. 

The cases are now kept recumbent for two or three weeks 
after operation, and are kef>t quiet for two months or so. They 
should wear a plaster for from four to six months and a sup- 
porting brace after that until a year from operation, and until 
a year has elapsed no unsupported weight should come on the 
silk. 

It is not necessary to disturb the foot to look at the wound, 



Il6 TREATMENT OF INFANTILE PARALYSIS 

but the patient wears the plaster applied at operation for 
three or four months. In careless patients it is well to continue 
the plaster for a year. The time of fixation in the earlier cases 
was as a rule much less than this which probably accounts for 
the less satisfactory results in the earlier cases of the series. 

The use of posterior ligaments at the ankle-joint to check 
dorsal flexion in cases of calcaneus has not proved satisfactory, 
nor is there any especial reason why it should, because in walk- 
ing the whole weight of the foot must come upon the ligament, 
and such mechanical conditions are the worst possible for se- 
curing success. After trying the method in a number of 
cases the writer is of the opinion that it is of no value in 
calcaneus. 

The use of internal articular silk ligaments to secure greater 
stability and to modify malposition in various joints has been 
described by Bartow and Plummer, 1 but the matter has not 
commended itself particularly to the writer because joint 
stiffness to a large extent must follow and in cases severe 
enough to require this operation it would seem better to 
perform an arthrodesis or other radical operation. The matter 
is, however, still sub judice, although some satisfactory results 
have been reported. 

Silk ligaments are sometimes used in connection with tendon 
transplantation. 

TENDON FIXATION OR TENODESIS 

The conversion of the tendons of the muscles passing over 
the ankle-joint into ligaments has been described by Tilanus, 1 
Codivilla, 2 Sangiori, 3 Reiner, 4 Jones, 5 and Gallic 6 As the last 
report of Gallie comprises 150 operative results his technique 
rather than that of the earlier writers will be described. 

The method consists in exposing and isolating the one or more 
of the paralyzed tendons whose support is desired. The tendon 

1 Tilanus: "Ned. Tijdschrift Voor Geneskunde," 1898, II, 23. 

2 "jour. Am. Orth. Assn.," August, 1911, p. 65. 
3 ' Revista de Ortopedia," 1901, No. 1. 

4 "Zeitsch. fur Orth. Chir.," 1903, Hft. 2. 

5 "Lancet", May 30, 1914. 

6 Gallie: "Annals of Surgery," March, 1913, October, 1915. "Am. Jour. 
Orth. Surg.," January, 1916. 



TENDON FIXATION 



117 




Fig. 76. — All the structures have been removed from the skeleton except the 
tibialis anticus muscle and tendon which has been buried in the tibia to prevent 
foot- drop. The stitches are shown. (Gallie.) 




Fig. 77. — Tendon of peroneus longus has been fixed in anterior border of 
external malleolus and tendon of peroneus brevis is ready to be laid in trough 
prepared for it behind the malleolus. (Gallie.) 



. 



n8 



TREATMENT OE INFANTILE PARALYSIS 



is drawn taut to correct the deformity — varus, valgus, equinus 
or whatever it may be — and is buried in a groove in the bone 
located in such a way as to counteract the deformity, scarified 
and sewed in place by kangaroo-tendon sutures passing through 
the tendon and the periosteum or cartilage at the sides of the 
groove. The skin wound is closed and the foot held by plaster 

in the corrected position for six 
weeks, after which walking is al- 
lowed. 

Excellent results on the whole are 
reported, and the advantage of the 
operation is that as in the silk-liga- 
ment operation dorsal flexion is al- 
lowed, but not plantar flexion in 
foot-drop, and it is also to be used 
in calcaneus where silk ligaments are 
of no use. The disadvantage is that 
it permanently throws out of use 
muscles which might improve under 
the favorable conditions of balance 
brought about by the operation and 
that the anchored tendons at times 
slip or stretch. The operation may 
be used in addition to tendon trans- 
plantation just as in the case of silk 
ligaments to serve as a reinforcement. 




Fig. 78. — The tendo achillis 
is fixed in the posterior sur- 
face of the tibia to prevent cal- 
caneus and the peroneal tendons 
have been transplanted into 
the os calcis. (Gallie.) 



ASTRAGALECTOMY 1 



One of the most useful operations in bad infantile paralysis 
of the leg has been devised by Whitman, 2 and is known as astrag- 
alectomy. It consists in the removal of the astragalus and the 
displacing of the foot backward on the tibia. The operation was 
originally devised for the treatment of cases of calcaneus in 
which the gastrocnemius was paralyzed and excessive dorsal 
flexion of the foot was present, but it has been applied to a larger 

1 "Annals of Surgery," February, 1908. 

2 ''Am. Jour.. Med. Sci.," November, 1902. 



ASTRAGALECTOM Y 1 1 9 

field of cases and is useful in cases of bad paralysis of the ankle 
where it is desired to secure greater stability of the foot, being 
in this matter preferable to arthrodesis, because in the modified 
operation as performed at the Children's Hospital, Boston, an 
ankyJosed ankle is not aimed at, but one allowing a slight de- 
gree of motion. The operation is performed in this modified 
form by using the Kocher incision at the outer side of the 
ankle-joint, sweeping down below the external malleolus and 
running forward to the base of the fifth metatarsal. The 
peroneal tendons are either pulled aside or divided and sutured 
afterward, and the astragalus is exposed and enucleated with 
the foot dislocated inward. This may be done by dividing it 
at the neck, which makes the technique a little easier, or the 
astragalus may be removed intact. After the astragalus is 
removed it is desirable to loosen the internal lateral ligaments 
of the ankle from the inner surface of the tibia in order 
that displacement backward of the foot may be thoroughly 
effected, and this is done subperiosteal^ by means of an osteo- 
tome and a blunt dissector. When this has been loosened up 
sufficiently to allow posterior displacement of the foot on the 
leg, the foot is displaced backward so that the two malleoli 
grasp the front of the os calcis instead of the astragalus. The 
surfaces of the tibia and the top of the os calcis are not in this 
technique roughened, but left normal with the hope of securing 
slight motion. The external ligaments are united by sutures 
and the foot done up in a position of slight equinus, in plaster 
of Paris. Weight should not be borne for at least three months. 
Even then it may be wise to support the foot for a while longer 
by a brace if it does not seem wholly stable. 

Occasional bad results come from astragalectomy in the way 
of distorted feet (varus, etc)., but on the whole with a proper 
technique the operation is satisfactory, and in many cases the 
result is excellent. Sometimes when there is slight muscular 
power left in one group of muscles it may be possible to add a 
muscle transplantation to an astragalectomy, the astragalec- 
tomy being done for the purpose of securing greater stability 
to the foot and the muscle transplantation to balance the 
foot to better advantage. 



120 TREATMENT OF INFANTILE PARALYSIS 

The original operation as described by Whitman is as follows: 

"An Esmarch bandage having been applied, an incision is made 
from a point about one inch above the external malleolus midway be- 
tween it and the tendo achillis, passing downward to the attachment of 
the tendo achillis, forward below the extremity of the malleolus and 
over the dorsum of the foot to the external surface of the head of the 
astragalus. The sheaths of the peronei tendons which are exposed at 
once, are opened throughout their entire length and the tendons, divided 
as far forward as the incision will permit, are thoroughly freed from all 
the attachments behind the malleolus and are drawn backward. One 
next divides the bands of the external lateral ligament, and the foot 
being somewhat adducted, the interosseous ligament is separated. On 
further inversion, the tissues being retracted, one may with scissors free 
the head of the astragalus from its attachment to the navicular, and 
forcibly twisting it outward, break off the cartilaginous margin to which 
the internal and posterior ligaments that cannot be reached are attached. 
One then prepares the new articulation. A thin section of bone is re- 
moved from the lateral aspect of the adjoining os calcis and cuboid bones, 
and from the internal surface of the external malleolus, which may be 
further shaped to secure accurate apposition. The same, but more 
difficult, procedure is undertaken on the inner side. One separates the 
internal lateral ligament from the malleolus sufficiently to permit the 
complete backward displacement, then removes the cartilage from its 
inner surface. .With the periosteal elevator the strong inferior calcaneo 
navicular ligament is detached sufficiently to permit the malleolus to 
sink in behind or to slightly overlap the navicular. Often the susten- 
taculum tali must be cut away to provide sufficient space for the broad, 
shallow internal malleolus. The two peronei tendons thoroughly freed 
from their attachments about the fibula are then passed through the 
base of the tendo achillis and sutured to it, and to the os calcis as well, 
at a sufficient tension to hold the foot in moderate plantar flexion. The 
tendo achillis is usually overlapped and sutured as an aid in restraining 
deformity. The Esmarch bandage is then removed, the part is thor- 
oughly cleansed with hot saline solution, and the bleeding points are 
ligatured. The wound is closed with continuous catgut sutures, rein- 
forced at several points with silk. The foot then carefully supported in 
its attitude of backward displacement and moderate plantar flexion 
with the malleoli fixed by slight pressure in their new relations, is thickly 
covered with sterilized sheet wadding and fixed by a light plaster bandage, 
particular care being taken to exert only the slightest constriction. The 
leg is then brought to a right angle with the thigh and the plaster bandage 
is continued over the thigh, reinforced by a band of steel in the popliteal 
region." 



TENDON SHORTENING 121 



TENDON SHORTENING 



A few words should be said about the operative shortening 
of stretched and elongated tendons in infantile paralysis be- 
cause it would be such an obviously simple thing to do if 
effective that it would have a wide application. But in general 
it is unsatisfactory probably because in most instances the 
conditions which caused the stretching in the first place are 
still existent and will cause it again, because paralyzed tendons 
appear to stretch under continued tension. 

The most obvious and well-known failure in this class of 
operation was the so-called Willet's 1 operation in which the 
tendo achillis was divided, shortened and sutured in cases of 
talipes calcaneus due to paralysis of the gastrocnemius, but 
the muscle stretched and the foot relapsed. 

Hoffa devised an operation embodying the same principle 
in calcaneo-cavus. The os calcis was sawed or chiselled through 
behind its articulation with the astragalus and set up, while 
the tendo achillis was reefed. In cases operated on by this 
method by the writer relapse occurred. 

Robert Jones has used an operation for talipes calcaneus of 
much the same character. The tendo achillis is split longi- 
tudinally and pulled apart by retractors exposing the posterior 
capsule of the ankle-joint. The foot is sharply plantar flexed 
and this posterior capsule is reefed as closely as possible by an 
over-and-over silk suture. The tendo achillis is then sewed 
together by stitches which shorten it by closing the longitu- 
dinal opening into a transverse one and the foot put up in the 
equinus position. Tendon transplantation may be added. 

The writer's experience with the reefing alone has been un- 
satisfactory, many cases relapsing and although in a gastroc- 
nemius partially paralyzed a recovery of power might occur, 
in a completely paralyzed muscle apparently stretching takes 
place.' 

SUMMARY 

The operative treatment of the various deformities may be 
summarized for convenience and are named in the order of the 

1 Alfred Willet: "St. Barth. Hosp. Rep.," 1880, vol. vi. 



122 TREATMENT OE INEANTILE PARALYSIS 

writer's preference but in the matter of such preference there 
is ground for a wide difference of opinion among experienced 
men. 

Talipes Equinus. — Stretching, tenotomy of the tendo achillis 
if the anterior muscles have fair power. Transplantation of 
the extensor of the great toe or other extensors into the tarsal 
bones, anterior silk ligaments with or without tenotomy, 
tenodesis, arthrodesis. 

Talipes Calcaneus. — Astragalectomy, tenodesis, arthrodesis. 

Talipes Varus. — Transplantation of the anterior tibial when 
that is active to the outer third of the foot. Silk ligament from 
the fibula to the cuboid, astragalectomy, tenodesis, arthrodesis. 

Talipes Valgus. — Transplantation of one of the peroneals to 
the inner side of the foot, silk ligaments from the tibia to the 
inner side of the tarsus, astragalectomy tenodesis or arthrodesis. 

Flexed Knee. — Stretching or open division of hamstrings. 

Hyperextended knee. — In cases where the quadriceps is para- 
lyzed and the hamstrings and gastrocnemius are good, trans- 
plantation of one or two hamstrings into the tubercle of the 
tibia. 

Knock-knee. — Supracondyloid osteotomy (Soutter's opera- 
tion). 

Flexed Hip. — Fasciotomy, if severe. 

Dislocated Hip. — Arthrodesis. 

Shoulder. — Dropping of the arm away from the glenoid 
cavity, arthrodesis of the joint, silk ligaments. 

In cases of deltoid paralysis with the pectoralis major active 
the origin of the latter may be transplanted into the spine 
of the scapula. 

Operation in the forearm elbow and wrist cannot be sum- 
marized as they vary greatly in individual cases. Arthrodesis 
of the elbow is useful but the operation is not applicable at 
the wrist on account of the nature of the joint. 



CHAPTER VI 
MUSCLE TRAINING 

EXAMINATION OF MUSCLES— OAIT— PRINCIPLES OF MUSCLE TRAIN- 
ING—METHOD—EXERCISES FOR EXAMINATION AND MUSCLE 
TRAINING 

It is obvious that any effective treatment of infantile 
paralysis, whether it be mechanical, by physical therapeutics, or 
by operation, must be preceded by a careful examination of the 
function and relative strength of the muscles involved as to 
whether they are normal, weakened, or unable to perform any 
function at all. Careless and inexact examination must obvi- 
ously lead to ineffective treatment. 

Inasmuch as the question of non-operative treatment is a 
matter of developing the power of voluntary muscular contrac- 
tion, the examination should necessarily concern itself with the 
amount of voluntary contractile power existing in the individual 
muscles. The examination by electricity gives certain informa- 
tion, but not the specific information which we wish. Such an 
electrical examination requires expert knowledge, it is difficult 
to confine the current to the individual muscles, and the result is 
in terms of contraction to electricity and not of contraction to 
voluntary impulse. What we want to know practically is the 
power of contraction to voluntary impulse, and to methods of 
examination directed to that end the present discussion will be 
confined. 

In any such examination it is important to note the existence 
of fixed deformity. 

GAIT 

In proceeding to the examination for the muscular diagnosis 
it is desirable first to see the patient walk if he is able to do 
so, because the problem of treatment is most often concerned 
with the walk and many important facts may be learned by 

123 



124 



TREATMENT OF INFANTILE PARALYSIS 



watching the gait if the patient is able to get about. In many 
cases a limp will persist through habit after the patient has 
recovered sufficient muscular power to enable him to walk with- 
out one. 

The following are some of the most characteristic gaits as 
modified by paralysis of individual muscles. In the descrip- 
tion of each gait it is assumed that all the other muscles are 
normal, but it should be kept in mind that there can be any 
combination of paralysis with consequent modification of the 
limp. 

Gastrocnemius. — The walk is heavy, the heel is brought down 
first and there is no spring when the next step is taken. If one 
side alone is affected the gait is arrhythmic, the 
patient pausing longer on the good foot. When 
both sides are affected the gait is waddling, with 
the feet turned outward. 

Dorsal Flexors of Foot. — The patient lifts 
the knee of the weak side high in order to clear 
the toes of the paralyzed foot, which "drop" 
when lifted from the ground. There is a tend- 
ency to extend fully or even hyperextend the 
knee when the foot is brought down. Weak- 
ness in one case was so slight as to escape de- 
tection by hand resistance, but the mother re- 
ported that the child fell down often, and it 
was discovered that she was unable to walk on 
her heels with her toes in the air. 

Anterior Tibial. — The patient walks with the weight on the 
inner border of the foot, which is pronated and everted (talipes 
valgus) . 

Peroneals. — When the peroneals are weak the patient walks 
on the outer side of the foot (talipes varus). 

Quadriceps. — With a weakened or paralyzed quadriceps 
muscle the patient may be able to walk unaided in the following 
ways: 

i. The patient keeps the knee fipm flexing as he walks by pressing the 
thigh back with one hand. 




Fig. 79. — Gait 
in paralysis of dor- 
sal flexors of foot. 



GAIT 



125 



2. As the affected foot touches the ground the patient hyperextends 
the knee, thereby locking the joint. 

3. The patient walks with the leg rotated outward. 

4. With talipes equinus the foot when placed on the ground locks the 
knee back because it cannot dorsally flex, and thus the knee is held 
extended and able to bear weight. 

5. With strong hamstrings the patient can lock the knee without hyper- 
extending or even fully extending it, simply by bending the whole body 
forward, the thighs thus carrying the center of gravity forward. 

Gluteus Maximus. — In stepping forward with the foot of the 
weak side the patient lightly touches the foot to the ground and 




Fig. 80. — Gait in 
paralysis of gluteus 
medius of right side. 





Fig. 81.— Gait 
in paralysis of hip 
flexors. 



Fig. 82.— Gait 
with abdominal 
paralysis. 



brings the good foot forward again very rapidly, with the knee 
of the good leg bent. The limp is very marked on account of 
the extreme dipping on the good side. When both gluteals are 
badly affected walking without crutches is impossible. 

Gluteus Medius {Hip A bductor) . — A patient with weak abduc- 
tors in walking takes his weight on the weak leg and tips his 
whole body toward that side and reaches out the hand for 
balance. This tipping and reaching out toward the weak side 
is very characteristic of abductor paralysis. In slighter cases 
it resembles the gait due to a short leg. 

Hip Flexors. — The patient brings the affected limb forward 
by a forward twist of the pelvis on that side. 



126 TREATMENT OF INFANTILE PARALYSIS 

Adductors of the Hip. — Weakness of the adductors does not 
cause a real limp, but it can be detected by asking the patient 
to place one foot directly ahead of the other in walking. With 
weak adductors this can only be done by swinging the body. 

Abdominal Muscles. — With weak abdominal muscles the 
patient stands and walks sway-backed, with the hips flexed and 
the lumbar spine in strong lordosis and with the abdomen 
prominent. Unilateral paralysis of the abdominal muscles, 
and especially of the quadratus lumborum, causes the patient to 
drop the pelvis on the weak side in taking the weight on the good 
leg. The position is like that taken by a patient with congeni- 
tal dislocation of the hip when standing on the affected leg 
(Trendelenberg's sign). 

Back Muscles. — Seriously weakened back muscles make it 
impossible for the patient to hold the spine erect in sitting, 
standing or walking. There is generally in these cases a lateral 
deviation of the spine. The more asymmetrical the paralysis 
the more rapid the onset of the scoliosis. 

MANUAL EXAMINATION OF THE MUSCLES 

The muscles should be examined individually as to their 
attempt to contract in response to voluntary impulse. Posi- 
tions favorable to the contraction of special muscles are chosen, 
and will be described in detail, and the patient is directed to 
perform a certain movement. During this movement the 
muscle under examination or its tendon is carefully watched 
for evidence of contractile power. There may be no response 
whatever, there may be a flicker of power, there may be fair but 
not normal power, or there may be normal power. 

By the examination of the individual muscles these facts may 
be determined and recorded on a chart. The chart used for 
this purpose and the method of recording such data were devised 
by Dr. E. A. Sharpe of Buffalo, and have been most satisfactory 
within their limits. (See Fig. 13.) 

In children too young or too unruly to obey such orders, much 
information, although far less exact, may be obtained by 
watching the voluntary movements of the child as it lies on 



MUSCLE TRAINING 1 27 

the mother's lap or on a table and analyzing them so far as 
possible. Movement may be stimulated by means of tickling 
or irritating the skin of the sole, the calf or the thigh, and by 
shifting the position of the child during this and during spon- 
taneous movement and struggling, and for the arm movements 
by holding out toys to be grasped. In these ways information 
may often be obtained which will throw light on the general 
distribution of the weakening or paralysis. 

It is very important for purposes of prognosis to distinguish 
as far as possible the action of individual muscles engaged in 
performing one movement. Suppose, for example, the power 
of the muscles flexing the elbow be represented in one case as 4, 
in which 1 stands for forearm muscles and 3 for biceps, and in 
another case as 4 also, of which 3 stands for forearm muscles 
and 1 for biceps, then in the first case we might reasonably 
expect a much better return of flexion power than in the second, 
as the biceps is much the more important flexor of the elbow. 

The method of examination described is not a mathematically 
accurate one, but it has the advantage of requiring no apparatus 
and of providing a graded series of tests for estimating muscular 
power. 1 

EXERCISES FOR MUSCLE TRAINING 

When the muscles have been examined by the method to be 
described, a set of exercises should then be worked out to suit 
the individual case and these exercises are given in connection 
with each movement and follow directly after the examination 
of each region. Naturally they are often the same as the 
examination. 

If a muscle is apparently without any power, the patient 
should concentrate his attention on the attempt to accomplish 
the movement while it is performed passively. It often hap- 
pens that weak muscles may be able to carry the limb through 
only a part of its normal are of motion. In such a case the 
limb should be carried by the surgeon passively through the 
remaining arc of motion normal to the joint and there should 

1 The anatomical authorities followed in the action of the leg muscles have 
been Cunningham and Piersol. When they have differed as to the function of 
a special muscle, the author has been quoted who credits it with that function. 



128 TREATMENT OF INFANTILE PARALYSIS 

be no pause after the muscle has ceased acting, but the assis- 
tance should come in time to make one smooth movement 
throughout the whole arc, in order that there may be no inter- 
ruption in the patient's mental effort. Not until muscles are 
capable of performing a movement through its whole arc 
should any additional resistance be given, and not until they 
are capable of performing the movement next in order of 
strength throughout its whole arc, should that movement be 
given in place of the easier one. 

When resistance is given, it should be graduated from weak 
at the beginning of the movement to strong in the middle, 
and to weak again at the end of the movement, in accordance 
with the change in leverage that takes place during the move- 
ment. The resistance at every point should be just a little 
less than would stop the movement. 

It is usually enough to let the patient go through all his 
exercises once a day six days in the week. The one day of 
rest prevents him from becoming stale. Each exercise may be 
performed ten or twelve times in succession in slow enough 
rhythm to allow for complete recovery between efforts. Unless 
it is done as well the second time as the first and the tenth as 
well as the second it is being done too fast and the patient 
should be given a rest at once. A few seconds are usually 
enough for recovery between successive attempts. 

If possible the patient should never be left to do his exer- 
cises alone, even when he is old enough to understand his own 
case. The response of muscle and nerve is dependent on the 
strength of the stimulus and the volition of the patient is 
greatly aided by the outside stimulus of a word of command. 
If the patient is a child the schemes for exciting interest and 
concentrating the attention on the effort to be made have to 
be varied every day, but there should not be any sacrifice of 
precision in the performance of the exercises. If the child is too 
young to make any intelligent effort at formal exercises the 
ingenuity of the mother will usually discover a means of 
bringing the affected muscles into play if she is made to under- 
stand what is required. Accuracy and precision are of the 
utmost importance in obtaining a proper result. Carelessly 



MUSCLE TRAINING 1 29 

performed exercises are of little value. In all exercise periods 
the whole attention of the patient should be required and it 
is desirable that no person except the one who directs the ex- 
ercises should be present — certainly no other child. 

While performing the exercises the paralyzed limbs should 
be uncovered, as the action of the muscles cannot be accurately 
observed through clothing. When the paralysis is extensive, 
the patient, if a young child, should be entirely undressed for 
a treatment. 

A table or other hard, smooth, horizontal surface, preferably 
not the floor, is necessary for the proper performance of the 
exercises, as it eliminates as much as possible the resistance of 
friction and enables a weak muscle to perform movements 
which would be wholly impossible for it on a soft yielding surface 
like that of a bed or couch. 

The regions will next be taken up separately, the examina- 
tion for each region given and the exercises to be prescribed will 
follow the examination in each region. 

The tests and exercises have been arranged in the order of 
their strength, those for normal or nearly normal muscles being 
given first. 

LOWER EXTREMITY 
The Foot 

Toes — Flexion. — Flexion of the toes is produced by the following mus- 
cles: flexor longus digitorum, four toes (acting on both joints); flexor 
brevis digitorum, four toes (acting on the first joint); flexor accessorius, 
four toes; flexor longus hallucis, big toe; flexor brevis hallucis, big toe; 
flexor brevis minimi digiti, one toe; lumbricales, four toes; interossei, 
three toes. 

Examination for Toe Flexion. — 1. The patient lies on the back or sits and 
bends the toes toward the sole of the foot, to "make a fist" with the foot. Com- 
plete paralysis of all toe flexors is rare. 

Exercises for Toe Flexors. — 101. The movement described in 1 (see Exami- 
nation) is performed (a) with resistance and (b) without resistance from the 
surgeon, who places one finger across underneath the toes and pushes up 
against them. 

Toes — Extension. — Extension is produced by the following muscles at 
the metatarso phalangeal joints: extensor longus digitorum; extensor 
brevis digitorum; extensor proprius hallucis; interossei; lumbricales 
(Cunningham). 
9 



130 



TREATMENT OE INFANTILE PARALYSIS 



Examination. — 2. The patient sits or lies on the back and bends the toes 
toward the dorsum of the foot. The surgeon may resist the movement with 
one finger placed on the dorsal surface of the toes. Normal toe extensors should 
be able to overcome considerable resistance. 

Exercises. — 102. The patient performs the movement described in 2 (a) with 
resistance, (b) without resistance. 

Ankle — Dorsal Flexion (Flexion). — Dorsal flexion of the foot is pro- 
duced by: tibialis anticus; extensor longus digitorum (Piersol); extensor 
communis digitorum (Cunningham); extensor proprius hallucis; pero- 
neus tertius. 

Examination. — 3. The patient stands on the foot to be tested and raises the 
front of the foot from the ground until he is balanced on the heel. For the per- 
formance of this motion the tibialis anticus and other muscles must be nearly 
normal. The toe extensors alone probably do not have power enough to per- 
form this movement. (See Fig. 83.) 




Fig. 



83. — Examination No. 3, 
dorsal flexion. 



Fig. 84. 



-Examination No. 4, dorsal 
flexion. 



4. The patient sits with the feet hanging free and tries to raise the foot against 
resistance on the dorsum, the leg being steadied. If the foot can be raised above 
a right angle in this position but 3 cannot be performed the muscles are not nor- 
mal but may be classed as good. If they cannot perform it gravity must be 
eliminated as in the following test. (See Fig. 84.) 

5. The patient lies on the affected side with the affected leg held firmly down 
on the table and the foot in plantar flexion and attempts to bring it into dorsal 
flexion. If the muscles act only in this position, they are very poor; if they do 
not act, they are paralyzed. Care must be taken not to confuse the rebound 
from extreme plantar flexion with real action of the dorsal flexors. 

Exercises. — 103. The patient performs the movement described in 3. 

104. The patient performs the movement described in 4 with and without 
resistance. 

105. The patient lies on the affected side and dorsally flexes the foot while the 
leg is held firmly down on the table. This eliminates pronation of the foot. 

106. The patient lies on the face with the knee flexed at right angles and the 
lower leg directed vertically upward. The surgeon studies the leg during at- 
tempted dorsal flexion of the foot (a) with the finger under the dorsum of the 
foot resisting the movement; (b) with gravity assisting the movement. 






MUSCLE TRAINING 131 

Plantar Flexion (Extension) of the Ankle. — The muscles concerned are: 
gastrocnemius; plantaris; soleus; tibialis posticus; peroneus longus and 
brevis; flexor longus digitorium; flexor longus haflucis. 

Examination. — 6. The patient stands on the affected side with the sound 
knee bent and steadied by holding the surgeon's hands with his own, rises on 
the ball of the affected foot (attempts to stand on tip toe). Normal plantar 
flexors can raise the body weight about ten times without flagging. 

7. The patient walks on tip toes. An affected muscle may be strong enough 
to permit this when it is too weak to perform the preceding movement. (See 
Examination 6.) 

8. The patient lies on the face with the feet projecting over the end of the table 
and attempts plantar flexion against the resistance of the surgeon's hand. When 
a patient is unable to stand, this test will indicate the amount of power in the 
muscles involved. (See Fig. 85.) 

9. The patient lies on the affected side with the leg held and attempts plantar 
flexion at the ankle. The tendo achillis must be closely watched in this 




I 
Fig. 85. — Examination No. 8, plantar flexion. 

attempted movement to see if any contraction of it occurs, as the tibial, 
peroneal, or long toe flexor may cause slight plantar flexion when the gastrocne- 
mius is wholly paralyzed and in the latter case the outlook is less good. 
Exercises. — 107. The movement is described in 6. (See Examination.) 

108. The movement is described in 7. 

109. The movement is described in 8. 

no. The patient performs the movement described in 9: (a) with resistance, 
(b) without resistance on the sole of the foot. 

in. The patient lies on the face with the knee flexed to a right angle and the 
lower leg directed vertically upward and plantar flexes the foot, (a) without 
assistance, (b) with assistance on the dorsum of the foot. 

Inversion of the Foot. — The muscles concerned are: Tibialis anticus; 
tibialis posticus. 

When the anterior tibial is paralyzed the extensor longus hallucis acts 
with some slight force to invert the foot. 

Examination. — 10. The patient lies on the affected side and while the leg is 
held firmly down on the table lifts the outer border of the foot away from the 
table with resistance from the hand on the inner border of the foot. To perform 



132 



TREATMENT OE INFANTILE PARALYSIS 



this movement both tibials must be very good and it is important to look for 
and identify the tendon of each when this movement is attempted for even with 
very weak muscles the tendons may be seen to contract. The peroneals must 
be relaxed before the movement is attempted as otherwise the rebound from their 
contraction might be taken for active movement. In case the extensor longus 
hallucis is acting to replace the tibialis anticus its tendon will be felt instead of 
the tibial tendon; normally both can be felt lying close together, the tibial tendon 
nearer the internal malleolus. 




<%=- 




-c^ 



Fig. 86. — Test for tibialis posticus. Fig. 87. — Test for tibialis anticus. 
Figs. 86 and 87. — Examination No. 11. 



11. The patient sits with the foot hanging free, with the lower leg held firmly 
and turns the foot inward in an attempt to touch the surgeon's finger which is 
first held slightly above the great toe on the inner border of the foot (tibialis 
anticus) and then held slightly below the inner great toe joint (tibialis posticus). 
(See Figs. 86 and 87.) 

Exercises.— 112. The patient attempts the movement described in 10, (a) with 
resistance on the inner border of the foot, (b) with help at the end of the 
movement. (See Fig. 88.) 




Fig. 88. — Exercise 112, inversion of foot. 




p. — Examination No. 12, 
eversion of foot. 



113. The patient sits on the edge of the table with the legs hanging down and 
the leg steadied by the surgeon. He then attempts to turn the front of the foot 
inward and upward toward the other ankle, (a) with resistance against the 
inner border of the foot, (b) with the resistance of gravity alone. 

114. The patient lies on his back, the surgeon holding the affected leg above 
the ankle to steady it and turns the foot inward toward the other ankle, (a) 
without help, (b) with help in accomplishing the movement. 

Eversion of the Foot. — The muscles concerned in this are: peroneus 
longus; peroneus brevis; peroneus tertius. 



MUSCLE TRAINING 133 

The extensor longus digitorum in the weakness of tibial muscles acts as 
an evertor of the foot. 

Examination. — 12. The patient sits with the foot hanging free, the lower leg 
steadied by the hand, and turns the foot outward to touch the surgeon's finger. 
(See Fig. 89.) 

Exercises. — 115. The patient sits as described in 12 and everts the foot, (a) 
against manual resistance, (b) with the resistance of gravity alone. 

116. The patient lies on his back with the affected leg held and turns the sole 
of the affected foot outward away from the other foot. 

Knee. — Flexion. — The muscles performing this movement are: biceps; 
semitendinosus; semimembranosus; gastrocnemius; popliteus; sartorius; 
gracilis (Cunningham). 

Examination. — The hamstrings which are the principal knee flexors are also, 
it must be remembered, extensors of the hip and for this reason are more power- 




Fig. 90. — Examination No. 13, knee flexion. 

ful than would be the case if their sole function were to lift the weight of the leg 
in flexing the knee in walking. 

13. The patient lies face downward and flexes the knee from the straight 
position until the heel touches the buttock, while the surgeon offers resistance 
over the back of the ankle. Considerable resistance can be overcome if the 
muscle is normal. If it cannot raise the weight of the leg, it is poor and gravity 
must be eliminated as in the next exercise. (See Fig. 90.) 

14. The patient lies on the affected side with the hip flexed and the knee ex- 
tended while the thigh is held firmly and attempts to flex the knee. If the mus- 
cles show no power in this position they must be classed as paralyzed and much 
information may be gained by feeling of their tendons during attempted move- 
ment. Paralysis of the gastrocnemius weakens the force of knee flexion even 
with normal hamstrings. The inner or outer hamstring may be paralyzed while 
the other will contract. (See Fig. 91.) 

Exercises. — 117. 13 describes this exercise. It should be done, (a) with re- 
sistance at the back of the ankle, (&) with the resistance of gravity. 

118. The exercise is the same as the examination in 14, (a) with resistance from 



134 



TREATMENT OF INFANTILE PARALYSIS 



the surgeon's hand on the back of the ankle, (b) by unaided muscular contraction 
(c) with assistance on the front of the ankle. 

119. The patient lies on the back while the surgeon holds up the affected leg 
steadying the thigh in the vertical position and offers resistance on the back of 
the leg as the patient flexes the knee. In this exercise gravity assists the move- 




Fig. 91. — Examination No. 14, knee flexion. 

ment and it is possible to add just the amount of resistance necessary to over- 
come gravity and as much more as can be overcome by the weakest muscles. 

Extension of the Knee. 
extensor. 



-The extensor of the knee is the quadriceps 



Examination. — 15. The patient sits on the heels, shifts all the weight onto the 
leg to be tested and comes up to the erect position on that leg, steadying himself 




Fig. 92. — Examination No. 15, knee extension. 



by holding the surgeon's hands. The muscle is normal if this movement can 
be performed with slight assistance. (See. Fig. 92.) 

16. The patient sits on a table with the knees flexed and the legs hanging over 
the table and attempts to extend the knee against resistance on the front of the 
ankle. The amount of resistance required to stop the movement will enable 






MUSCLE TRAINING 135 

the surgeon to judge its power especially if the muscle on the other side is normal 
and can serve as a comparison. If the quadriceps cannot raise the weight of the 
leg, it is poor. 

17. The patient lies on the affected side with the hip fully extended and the 
knee flexed and attempts to straighten the knee. If no contraction is found in 
this position the muscle must be classed as wholly paralyzed. (See Fig. 93.) 

Exercises. — 120. The patient performs movement 16, (a) with resistance from 
the surgeon on the front of the ankle, (b) with the resistance of gravity alone. 

i2i. The patient performs 17, {a) with resistance on the front of the ankle, 
(b) unaided, or (c) with assistance. 

122. The patient lies on the face with the knee flexed to a right angle and ex- 
tends the knee against resistance. 

123. The patient lies face down on a table with the hips flexed and legs hanging 
over the edge of the table. The surgeon steadies the affected thigh with his 
hand and with his other hand flexes the knee and holds it in front of the ankle 
while the patient attempts to extend the knee with the help of gravity. 




Fig. 93. — Examination No. 17, knee extension. 

Hip. — Flexion. — The muscles performing this movement are: sartorius; 
psoas major and iliacus; rectus femoris; pectineus; adductor longus; gra- 
cilis; obturator externus (Piersol); adductor brevis (Cunningham). 

Examination.— 18. The patient sits with the lower legs hanging over the edge 
of a table and raises the knee to the chest with resistance at the front of the thigh 
just above the knee. Normal muscles should overcome much resistance. {See 
Fig. 94.) 

19. The patient lies on the affected side, the surgeon supporting the other leg 
and attempts to draw the knee up to the chest. Muscles which show no power 
in the position must be counted as paralyzed. (See Fig. 95.) 

During this movement it may be possible to distinguish between the contrac- 
tion of the sartorius and rectus femoris by placing one finger on the anterior 
superior spine and one on the inferior and feeling from which of them the con- 
tracting muscle originates. 



136 



TREATMENT OF INFANTILE PARALYSIS 



124. The patient performs 18, (a) with resistance, {b) without resistance. 

125. The patient lies on his back and brings his knee up to his chest, (a) with 
resistance, (b) without other resistance than the weight of the leg. 




Fig. 94. — Examination No. i8,[flexion of hip. 




Fig. 95. — Examination No. 19, flexion of hip. 




Fig. 96. — Examination No. 21, extension of hip. 



126. The patient performs 19, (a) with resistance against the front of the thigh, 
(b) without resistance, (c) with assistance. 



MUSCLE TRAINING 



137 



Exercises. — 127. The patient lies face down on a table with the legs hanging 
over the edge, being flexed at the hip-joints. The affected leg is then raised to 
the horizontal by the surgeon and from this position the patient flexes the hip 
with the surgeon supporting as much of the weight of the leg as may be required. 

Extension of Hip. — The muscles performing this movement are: glu- 
teus maximus; hamstrings; gluteus medius (Cunningham); gluteus mini- 
mus (Cunningham); adductor magnus (Cunningham). 




Fig. 97. — Examination No. 20, extension of hip. 

Examination. — 20. The patient lies on the face and hyperextends the hip with 
the knee straight, raising the leg from the table. Considerable resistance can 
be overcome by normal muscles. (See Fig. 97.) 

21. The patient lies on the affected side with the hip fully flexed and moves 
the thigh back into the line of the body. If there is no movement in this position 
the muscles must be considered paralyzed. Slight power to extend the hip may 
be found where the gluteals are paraly zed and only the hamstrings acting. 
(See Fig. 96.) 




Fig. 98. — Examination No. 22, abduction of hip. 

Exercises. — 128. The patient performs 20, (a) with resistance, (b) without re- 
sistance — without twisting the body. 

129. The patient lies face downward on a table with the hips flexed over the 
edge and the legs hanging down. In this position he raises the leg to the hori- 
zontal, (a) with the resistance of gravity alone, (b) with resistance on the back 
of the thigh. 

130. The patient performs 21, (a) with resistance, (b) unaided, (c) with assist- 
ance. 

131. The patient lies on the back and the affected leg with the knee straight 



138 TREATMENT OF INFANTILE PARALYSIS 

is lifted as high as possible by the surgeon and the patient brings the leg back to 
the table with the surgeon making as much resistance as can be overcome. 

Abduction of the Hip. — The muscles concerned are as follows: gluteus 
medius; gluteus minimus; tensor fasciae femoris (Cunningham); obtura- 
tor externus (Cunningham); during flexion, pyriformis, obturator inter- 
nus, gemelli; sartorius, gluteus maximus (upper fibers) (Cunningham). 

Examination. — 22. The patient lies on the sound side and raises the affected 
leg with the knee straight and in line with the body. The normal muscle over- 
comes considerable resistance. (See Fig. 98.) 

23. The patient lies on the back with the pelvis firmly held to prevent throw- 
ing of the body and abducts the affected leg. Outward rotation of the foot must 
be checked or flexors will be substituted for abductors. 

24. In order to eliminate the possibility that friction of the heel on the table 
may overcome weak muscles the leg may be slung by a bandage under the ankle, 
the upper end being held by the surgeon, and the same movement attempted. 
If no motion occurs, the abductor muscles are paralyzed. 




Examination No. 25, adduction of hip. 



Exercises. — 132. The patient performs 22, (a) with resistance, (b) without 
resistance. 

133. The patient performs 23, (a) with resistance, (b) without resistance, (c) 
by aid of a sling. (See Examination 24.) 

Adduction of the Hip. — The muscles performing this movement are: 
adductors longus, magnus, brevis; gracilis; pectineus; quadratus femoris 
(Cunningham); gluteus maximus (lower fibers) (Cunningham). 

Examination. — 25. The patient lies on the affected side with the sound leg 
held by the surgeon in a position of abduction. He then raises the affected leg 
from the table in line with the body with the knee straight and without rotating 
it. Considerable resistance can be overcome. (See Fig. 99.) 

26. The patient lies on the back with the affected leg in extreme abduction 
and brings it in to the other leg. 

27. To eliminate friction a sling may be used and the movement of adduction, 
attempted. (See Examination 24.) 

Exercises. — 134. The patient attempts the movement described in 25, (a) with 
resistance, (b) without resistance. 



MUSCLE TRAINING 



139 






135. The patient lies on the back with the knees and hips flexed, with the soles 
resting on the table and the knees apart and attempts to bring the knees together, 
(a) with resistance against the inner side of the knees, (b) with only the resist- 
ance of gravity. 

136. As in 26, (a) with resistance, (b) unaided, (c) by the use of a sling. 

Inward Rotation of the Hip. — The muscles are: tensor fasciae latae; 
gluteus medius (anterior fibers) ; gluteus minimus (anterior fibers) ; semi- 
tendinosus (Piersol); semimembranosus (Piersol); gracilis (Piersol); ilio- 
psoas (Piersol). 

These muscles are all concerned also with other functions which have 
been mentioned in earlier sections. 





Fig. 100. — Examination No. 
inward rotation of hip. 



Fig. ioi. — Examination No. 31, 
outward rotation of hip. 



Examination. — 28. The patient sits with the knees flexed and the lower legs 
hanging over the edge of a table, keeping the knees together he moves the affected 
foot away from the other foot, thus rotating the thigh inward. Resistance is 
offered on the outer side of the ankle. (See Fig. 100.) 

29. The patient lies on the back and rotates the whole leg inward. The feet 
should be somewhat separated and rotated outward at the start. 

Exercises. — 137. The movement described in 28 is performed, (a) with resist- 
ance, (b) with the resistance of gravity alone. 

138. As in 29, (a) with resistance, (b) without resistance. 

Outward Rotation of the Hip. — This is performed by the following mus- 
cles: gluteus maximus (lower fibers); gluteus medius (posterior fibers) 
(Cunningham); gluteus minimus (posterior fibers) (Cunningham); quad- 
ratus femoris; during extension, obturator externus, pyriformis, gemelli; 
sartorius; iliopsoas (Cunningham); pectineus; adductors magnus, longus, 
brevis, (Cunningham); biceps femoris; obturator internus. 

The action of the iliopsoas is given by Piersol as an inward rotator and 
by Cunningham as an outward rotator. 



140 TREATMENT OF INFANTILE PARALYSIS 

Examination. — 30. The patient lies on the face with the knees flexed, the lower 
legs upright and the knees touching and the feet are allowed to fall apart. The 
legs are then rotated so as to bring the feet together. 

31. The patient sits at the edge of the table with the knees flexed and the feet 
hanging down. The foot of the affected leg is then moved inward across the 
other leg twisting the thigh outward. (See Fig. 101.) 

Exercises. — 139. 31 is performed, (a) with resistance, (b) without resistance. 

140. The patient lies on the back with the knees straight and legs slightly 
separated, the toes pointed up and the pelvis held to prevent rolling and turns 
the whole leg outward, (a) with resistance, (&) by unaided muscular contraction, 
(c) with assistance. 

Spinal Column — Flexion of the Spine (Forward Bending). — The muscles 
concerned are: rectus abdominis; pyramidalis (Cunningham); obliquus 
externus; obliquus internus; transversus abdominis (Cunningham) ; psoas 
major and minor. 

Examination. — 32. The patient lies on the back with the arms folded, 
the thighs being held down by the surgeon and attempts to assume the sitting 
position. 

If the muscles are normal the ensiform cartilage is drawn toward the symphysis 
by the recti, assisted by the other abdominal muscles, thus flexing the lumbar 
spine; then the psoas and iliacus and other hip flexors flex the pelvis on the thighs. 
If the hip flexors are paralyzed, normal abdominal muscles cannot raise the 
patient to a sitting position, but by placing the hand over them as they contract 
it is possible to feel them hard and to judge by their tone and by the ease with 
which the lumbar spine is flexed whether or not they are normal. If, on the 
other hand, the recti are paralyzed and the hip flexors normal, the patient will 
first fix the lumbar spine by contracting the erector spinae muscles and then flex 
the pelvis on the thighs with the back hollowed and the abdomen prominent 
and soft. The abdominal muscles of one side may be affected more than those 
of the other, a fact which may be ascertained by feeling the muscles of either side 
as they attempt to contract and by watching to see whether the umbilicus is 
drawn to one side or the other. 

Exercises. — 141. The patient sits in a semireclining position with the back 
against a slanting support, with arms folded and knees held down and tries to 
assume a sitting position. The resistance is offered by the weight of the body 
and the exercise may be made more difficult by starting from a position of the 
trunk nearer the horizontal. 

142. The patient lies on the back and flexes the knees onto the chest, if neces- 
sary with assistance under the knees. 

143. The patient lies on the side with the arms folded on the chest and the hips 
firmly held and flexes the spine by bending the body forward. Resistance is 
offered by the friction of the body on the table. This exercise should be done 
with the patient lying first on one side and then on the other. 

Extension of the Spine. — Produced by the contraction of the erector spinoe, 
a name used here to describe the whole group of posterior spinal muscles 
instead of the complicated more modern nomenclature given in Piersol and 



MUSCLE TRAINING 141 

Cunningham. These muscles cannot be exercised without at the same 
time exercising the extensors of the hips. 

Examination. — 33. The patient lies on the face with the legs held down by the 
surgeon, and tries to raise the head and trunk from the table. 

If the erector spinae muscles are normal they can bend the spine backward 
and raise the head, shoulders and whole body clear of the table and can be felt 
as two prominent columns on each side of the spine. When they are not strong 
enough to lift the weight of the body, they may be still felt to contract by placing 
the fingers on each side of the spine. It is not easy to eliminate gravity in test- 
ing these muscles, so that their presence or absence must be judged by whether 
or not they can be felt contracting when the patient attempts to lift the body. 
Frequently the muscles of one side are good, while those of the other are paralyzed 
or very weak. In such a case the patient always sits or stands, and sometimes 
even lies with the spine curved laterally, although a lateral curvature may occur 
also as a result of asymmetrical abdominal weakness. 

Exercises. — 144. The patient performs the movement described in 33. Re- 
sistance is furnished by the weight of the trunk. 

145. The patient sits with the trunk bent forward, the hips flexed and raises 
the trunk to the erect position, (a) with the hands behind the neck and the el- 
bows squared (the stronger exercise), and (&) with the hands on the hips (the 
weaker exercise). 

Lateral Flexion of the Spine {Side Bending) . — The most important mus- 
cles taking part in this movement, which is not to be clearly separated 
from the following movement of rotation, are as follows: rectus abdom- 
inis; obliquus externus and internus; transversus abdominis; erector spinae; 
psoas major and minor; quadratus lumborum. 

Examination. — 34. The patient lies on the unaffected side, the legs in line with 
the body andlield down by the surgeon with the arms folded and attempts to 
lift the body up from the table. This is easily accomplished if the muscles are 
normal. If they are very weak, the muscles on the other side will contract and 
the affected side of the body will be arched up from the table between the hip and 
shoulder. 

35. The patient lies on the back with the arms folded, the hips being held 
firmly by the surgeon and attempts to bend the body toward the side to be tested. 

Exercises. — 146. The patient performs 34. 

147. The patient performs 35. 

148. The patient stands and raises the foot of the affected side from the floor 
without bending the knee, or the patient lies on the face and draws the affected 
side of the pelvis up toward the shoulder of the same side keeping the knee 
straight and dragging the leg up along the table, (a) with resistance on the 
ankle, (b) without resistance. 

Rotation of the Spine. — It has been mentioned that this movement is 
not clearly to be separated from lateral flexion. The muscles chiefly 
concerned are: erector spinas; obliquus externus and internus. 



142 



TREATMENT OF INFANTILE PARALYSIS 



Examination. — 36. The patient sits with arms folded, the hips held firmly, 
and twists the body to one side, (a) with resistance, (b) without resistance. 

Exercises. — 149. See 36. 

In formulating the movements of the arm Beevor's 1 Croonian lectures on 
muscular movements have been used as the basis of the analysis and have proved 
of the greatest use. 

UPPER EXTREMITY 

The Hand. — Fingers. — The examination of the fingers and exercises for 
weakened muscles will be dealt with only in general for the sake of brevity 




Fig. 102. — Test for finger flexion. 

and because the examination of the different motions is perfectly obvious 
and the exercises similarly simple. An attempt should be made to per- 
form the various movements with slight resistance offered by the surgeon 
and the exercises are similarly given. The opposing and adducting 
muscles of the thumb should be examined with care in every case whether 




Fig. 103. — Test for thumb adduction. 

the hand appears involved or not as involvement of these muscles is 

extremely common. 
The function of the different groups is given by Cunningham 2 as follows : 
Plexion. — Flexor digitorum sublimis; flexor digitorum profundus; 

lumbricales; interossei (acting on the metacarpo-phalangeal articulations; 

flexor digiti quinti brevis). 

1 Chas. E. Beevor, M. D., London, F. R. C. P.: "The Croonian Lectures on 
Muscular Movements and Their Representation in the Central Nervous System," 
London, Adlard & Son, 1904. 

2 Cunningham's "Text Book of Anatomy," Robinson, N. Y., Wm. Wood & 
Co., 1913. 



MUSCLE TRAINING 143 

Extension. — Extensor digitorum communis; extensor indicis proprius; 
extensor digiti quinti proprius; lumbricales; interossei (acting on the inter- 
phalangeal articulations). 

Abduction. — Lumbricales; flexor brevis and opponens digiti quinti (from 
the medial side of the hand); dorsal interossei (from middle line of middle 
finger) . 

Adduction. — Palmar interossei (to the middle line of the middle finger). 

Thumb. — Flexion. — Opponens pollicis (carpo-metacarpal joint) ; flexor 
brevis, adductor, abductor brevis (carpo-metacarpal and metacarpo- 
phalangeal joint); flexor pollicis longus (all joints). 

Extension. — Abductor pollicis (carpo-metacarpal joint); extensor pol- 
licis brevis (carpo-metacarpal and metacarpo-phalangeal joint) ; extensor 
pollicis longus (all joints). 

Adduction. — Adductor of the thumb; flexor pollicis brevis; opponens 
pollicis; first dorsal interosseous. 

Abduction. — Abductor pollicis brevis; extensors of the thumb. 

Circumduction. — A combination of the above muscles. 

Wrist. — Flexion. — This motion is performed by the following muscles: 
flexor carpi radialis; flexor carpi ulnaris; palmaris longus; long flexors of 
thumb and fingers. 

Examination. — 37. The patient sits with the forearm supported on the table and 
the hand extending over the edge with the palm up. The wrist is flexed against 
the surgeon's resistance. The finger flexors will assist the wrist flexors proper 
if the fingers are flexed in the palm of the hand. 

38. The forearm and hand are supported, ulnar side down, on a table with the 
wrist hyperextended and an attempt is made to flex the wrist. 

Exercises. — These are the same as the examination. 

Extension of the Wrist. — The muscles are: extensor carpi radialis; 
extensor carpi ulnaris; extensors of the thumb and fingers. 

Examination is the reverse of that described in 37 and 38 and the exercises 
are the same movements as described in 37 and 38 reversed, j 

Abduction of the Wrist. — Muscles: Flexor carpi radialis; extensors of 
wrist and thumb. Extensor carpi radialis longior (Piersol.) 
Adduction. — Flexor carpi ulnaris; extensor carpi ulnaris. 

Examination. — 39. The patient sits with the arm resting on a table, ulnar side 
down, and the movements of adduction and abduction are tested by the surgeon 
who resists each attempted movement. 

40. If the muscles are too weak to give satisfactory information in this posi- 
tion the forearm should rest on the table, palm up, and adduction and abduction 
be tested (a) with resistance, (b) unaided. 

Exercises. — These are described under examination. 

Pronation of the Forearm and Hand. — The muscles concerned are: 
pronator radii teres; pronator quadra tus; flexor carpi radialis. 



144 TREATMENT OF INFANTILE PARALYSIS 

(The brachioradialis (supinator longus) is given as a pronator from ex- 
treme supination by Cunningham but is regarded purely as a flexor by 
Beevor and is considered to have also slight supinator power by Piersol. 
The view of Beevor will be followed here.) 

Examination. — 41. The patient sits with the forearm resting on the lap, palm 
up. The surgeon grasps the hand and resists pronation. The exercise is given 
without resistance when the muscles are very weak. The exercises are the same 

Supination of the Forearm and Hand. — Supinator (supinator radii 
brevis); biceps; brachioradialis (Cunningham). 

Examination. — 42. The patients sit with the forearm resting on the lap, palm 
down. The surgeon grasps the hand and resists attempted supination. The 
test is given without resistance when the muscles are very weak. (See Fig. 104.) 




Fig. 104. — Examinations Nos. 41 and 42, test for pronation and supination. 

As the biceps is a powerful flexor as well as supinator, when it is weakened, 
strong supination will be accompanied by extension at the elbow and when the 
triceps is weakened and the biceps intact, by flexion of the elbow. 

Exercises. — These have been described in 42. 

Elbow. — Flexion. — The muscles are: biceps; brachialis; brachioradi- 
alis; pronator teres; flexors of wrist and fingers; extensors of wrist and 
fingers (in pronation) . 

(The biceps should be regarded as a flexor supinator and the pronator 
teres as a flexor pronator. If there is weakness of the biceps it is extremely 
difficult to flex the elbow without pronating the hand, although normally 
the elbow can be flexed with the forearm either in pronation or supination.) 

Examination. — 43. The patient sits and bends the elbow until the hand touches 
the shoulder, while the surgeon offers resistance against the wrist. This move- 
ment should be done first with the hand in complete pronation, then with the 
hand in complete supination, in order to try out the different muscles taking part 
in it. If the weight of the arm cannot be raised gravity must be eliminated. 

44. The patient lies on the .affected side, with the arm straight, and flexes the 
elbow until the hand touches the shoulder, first in pronation, then in supination. 
No response in this position must be set down to complete paralysis of all the 
muscles involved. 

It is important to find out what proportion of elbow flexor power is due to the 
biceps, as a favorable prognosis depends on the hope of getting back power in 
that muscle. The other elbow flexors can lift the weight of the arm when the 



MUSCLE TRAINING 



145 



biceps is completely paralyzed, but can do very little more. Biceps paralysis is 
usually accompanied by pronation contracture. 

Exercises. — 150. As described in 43, (a) with resistance, (b) unaided. 

151. As described in 44, (a) with resistance, (b) unaided, (c) with assistance. 
(To exercise the biceps the forearm must be supinated.) 

152. The patient lies on his back, the upper arm supported vertically and 
flexes the elbow while the surgeon resists the movement. 

Extension of the Elbow. — Triceps; anconeus; extensors of wrist and 
fingers (in supination) (Cunningham, not Piersol or Beevor). 



Examination. — 45. The patient sits with the upper arm raised forward as 
far above the shoulder height as possible and supported in that position, the 
elbow is completely flexed so that the hand touches 
the shoulder. He then extends the forearm against re- 
sistance on the wrist. (See Fig. 105.) 

If the muscles cannot raise the weight of the arm, 
gravity must be thrown out of play. 

46. The patient lies on the affected side, with the 
elbow flexed and the hand touching the shoulder, and 
tries to extend the forearm. 

If this movement cannot be performed the muscles 
are paralyzed. 

Exercises. — 153. The patient lies on his back with 
the upper arm vertical and the elbow flexed and attempts 
to extend the elbow, (a) with resistance, (b) unaided 
against the weight of the arm above. 

154. The patient sits with the forearm held up in 
flexion by the surgeon and attempts to extend the 
elbow. The surgeon makes such resistance at the wrist 
as may be necessary to neutralize the weight of the 
forearm and offering weak resistance if it can be over- Fig. 105. — Examina- 
come. tion No. 45, extension 

of the elbow. 
SHOULDER 

In the analysis of movements of the upper extremity so far given Cun- 
ningham, Piersol and Beevor have been consulted as the authorities and 
their divergent views given when they were different. In analyzing the 
extremely complicated movements of the shoulder Beevor 's very complete 
study of this region will be followed, and his terminology of muscles and 
movements will in this section be adopted, and the others quoted only 
occasionally. In practice the method founded on Beevor's views has 
proved most satisfactory. 

Movements of the Shoulder -joint. — Advancing or flexion of the humerus 
to the horizontal line, antero-posterior plane (raising the arm forward): 
deltoid (anterior); pectoralis major (clavicular); biceps; coraco-brachia- 
lis (?). 




146 TREATMENT OF INFANTILE PARALYSIS 

Advancing or flexion of the humerus above the horizontal line: serratus 
magnus; trapezius (acromial); trapezius (inferior). 

The first set of muscles contract and carry the humerus forward nearly to 
the horizontal line, an action which would rotate the scapular downward 
and push the inferior angle toward the spinal column if the trapezius did not 
immediately contract to fix the scapula. The serratus magnus probably 
does not contract at the beginning of the movement, but comes to the aid of 
the other muscles as the humerus approaches the horizontal line. If the 
trapezius is paralyzed, the inferior angle of the scapula will first be drawn 
toward the spine as the arm is raised, but when the humerus has passed 
through about 45 degrees, the serratus will start contracting and rotate 
the scapula upward. There is apparently a definite order in which the 
separate muscles taking part in any given movement enter into action. 




Fig. 106. — Examination No. 49, advancing or flexion of the humerus. 

Examination. — 47. The patient lies on the face, with the arms stretched for- 
ward above the head, and raises the arms from the table without raising the body. 
If all the muscles enumerated above are normal the patient will be able to raise 
the arms somewhat above the line of the body while the shoulders are kept in 
contact with the table, and will be able at the same time to overcome some resist- 
ance. If the arms cannot be brought up to a line with the body, there is either 
some muscular weakness or joint contracture or both. 

48. The patient stands or sits, and raises the arm forward and upward against 
resistance on the front of the elbow. 

4Q. The patient raises the arm forward while the surgeon fixes the shoulder 
girdle by pressing firmly down between the patient's neck and the point of his 
shoulder. (See Fig. 106.) 

In test 48 all the muscles concerned in this movement act. In 49 the ser- 
ratus magnus and trapezius are thrown out of action, and only those muscles 
act which advance the shoulder to the horizontal. By comparison of the two 
tests the relative weakening of the two sets of muscles is shown. 

All the tests of this movement are to be used primarily to ascertain the 
condition of the trapezius and serratus magnus. 



MUSCLE TRAINING 1 47 

Abduction of the humerus to the horizontal line, latero-vertical plane: 
deltoid (middle); supraspinatus; biceps. 

Abduction of the humerus above the horizontal line (raising the arm from 
the side): seratus magnus; trapezius (acromial); trapezius (inferior). 

If the deltoid is paralyzed the trapezius and serratus will begin to act 
at once when the patient attempts to raise the arm sideways, and the 
inferior angle of the scapula will be seen to move outward, but the arm will 
be carried no more than 45 degrees from the side. To eliminate the action 
of the trapezius and serratus magnus the surgeon should fix the patient's 
shoulder girdle by downward pressure so that movement cannot take 
place above the horizontal. 

Examination. — 50. The patient stands or sits, and raises the arm straight side- 
ways to shoulder height, against resistance. The arm should not be allowed to 




Fig. 107. — Examination No. 50, abduction of the humerus. 

rotate outward, and the palm should be directed downward, as in this position 
the action of the biceps is excluded as much as possible from the movement. 
A normal deltoid can overcome considerable resistance besides the weight of 
the arm. (See Fig. 107.) 

51. The patient lies on the back or on the face, and moves the arm out from 
the side to shoulder height. The same care is to be taken as in the previous test 
for position of the hand and fixation of the shoulder girdle. If the test is given 
with the patient lying on his back the greater part of the work is done by the 
anterior fibers of the deltoid; if on his face, by the posterior. It may well be 
that either half may show power while the other is totally paralyzed. 1 If the 
muscle does not functionate at all in this position it may not be totally paralyzed, 
on account of friction, but is certainly extremely weak. 

A more delicate test can be made by slinging the arm under the elbow with a 
piece of bandage held far enough above so that the patient's movement is not 
assisted by it, but the friction of the arm on the table surface is removed. 

Exercises. — 155. The patient sits erect and with the arm at the side and raises 
the arm sideways until it is vertically above the head with the precautions 
described in 50, (a) with resistance, (b) raising the weight of the arm without 
resistance. 

156. As described in 51, (a) with resistance, (b) unaided, (c) by means of a sling. 

1 R. W. Lovett: Jour. A. M. A., Mar. 4, 19 16. 



148 TREATMENT OF INFANTILE PARALYSIS 

Extension of the humerus, anteroposterior plane (bringing the arm down- 
ward and forward): pectoralis major (sternal); latissimus dorsi; teres 
major and minor; infraspinatus; triceps (long head); subscapularis (?). 

By per extension of the humerus (carrying the arm back of the body) : lat- 
issimus dorsi; teres major and minor; infraspinatus; deltoid (posterior 
half). 

During both parts of this movement the scapula is fixed by the rhom- 
boids, the lowest fibers of the trapezius, and the pectoralis minor. 

Examination. — 52. The patient stands or sits with the arm in a vertical posi- 
tion above the head, and brings the arm forcibly forward and downward until 
it is in line with the body, while the surgeon offers resistance against the back of 
the arm just above the elbow. He must judge by the amount of resistance they 
can overcome whether or not the muscles are normal. Beevor is of the opinion 
that the clavicular portion of the pectoralis major, which is properly a flexor of 
the humerus, does not act in this movement, although it is in an anatomical 
position to do so. 




Fig. 108. — Examination No. 54, hyperextension of humerus. 

53. The patient stands or sits with the arm hanging at the side and raises it 
backward as far as possible, while the surgeon resists on the back of the arm as 
before. The pectoralis major no longer acts, but the pectoralis minor may be 
felt contracting beneath it. This test is a means of distinguishing between their 
action. 

54. The patient lies on the face with the arm at the side and raises it backward 
with resistance. This is an even more powerful test for the latissimus dorsi and 
posterior half of the deltoid. It is impossible to isolate the action of the latissi- 
mus dorsi, but some idea of its relative share in this movement may be obtained 
by feeling the muscle during the effort to contract. (See Fig. 108.) 

Exercises. — The exercises afe the same as the examination. 

Adduction of the humerus, latero- vertical plane (bringing the arm to 
the side): pectoralis major (all); latissimus dorsi; teres major and 
minor; infraspinatus; subscapularis (?); deltoid (posterior third). 

As in the previous movement the rhomboids and the lowest fibres of 
the trapezius fix the scapula. When they are paralyzed and the arm 



MUSCLE TRAINING 1 49 

is forcibly brought down to the side, the inferior angle of the scapula is 
drawn outward away from the spine. When they are normal and the 
adductors are paralyzed an attempt to adduct brings the inferior angle 
of the scapula toward the spine. 

Examination. — 55. The patient stands or sits and pulls the arm down to the 
side against resistance under the elbow. 

Whether or not the muscles are normal must be judged by the amount of 
resistance they can overcome and by the hardening of the tendons, which are 
easily felt at the anterior and posterior borders of the axilla. 

56 The patient lies on the back or on the face, with the arm stretched side- 
ways at right angles to the body, and draws the arm in to the side. 

The position on the back shows up the pectoralis best, that on the face, the 
latissimus. If the muscles are too weak to overcome the resistance of the arm 
on the table the arm may be slung as in the deltoid test. If there is then no 
sign of function the muscles must be classed as totally paralyzed. 




FIG. 109. — Examination No. 59, horizontal abduction of humerus. 

Exercises. — 157. The patient performs 55. 

158. The patient lies on the back with the arm stretched above the head and 
brings it to the side, (a) with resistance, (b) unaided, (c) with the aid of a sling 
to remove friction. 

Horizontal adduction of the humerus (bringing the arm toward the 
middle line of the body at shoulder level): coraco-brachialis; pectoralis 
major; deltoid (anterior half). 

Examination. — 57. The patient lies on the back with the arms stretched out 
sideways at shoulder height, elbows straight, palms up and raises the arms toward 
the middle line of the body until they are vertical and the palms meet above 
against resistance. 

The deltoid does not take part in this movement to any considerable extent, 
so that it is as pure a test as can be found for the pectoralis major. 

58. The patient sits with the affected side toward the table, upon which the 
arm is supported at shoulder height, and tries to slide the arm forward along the 
table. 

Exercises. — 159. See 57, (a) with and (b) without resistance. 

160. See 58, (a) with resistance, (b) unaided, (c) with a sling. 



i5° 



TREATMENT OF INFANTILE PARALYSIS 



Horizontal abduction of the humerus (carrying the arm back at shoulder 
level): deltoid (middle); deltoid (posterior); latissimus dorsi; teres major 
and minor; infraspinatus; subscapulars (?). 

In this movement the middle fibers of the trapezius fix the scapula. 

Examination. — 59. The patient lies on the face with the arm stretched side- 
ways at right angles to the body, and raises the arm straight up from the table, 
with resistance from the surgeon. (See Fig. 109.) 

If the deltoid is normal and the trapezius paralyzed the arm will be raised from 
the table, but the point of the shoulder will be pushed forcibly against the table 
and used for a pivot. If the condition is reversed the scapula will be drawn 
toward, the spine and the point of the shoulder raised from the table with the arm 
dragging down. 

60. The patient sits facing the table with the arm resting on it in a position 
of extreme adduction, that is, crossed over to the other side, and tries to abduct 
the arm. 

Exercises. — 161. The same as 59, (a) with resistance, (b) without. 

162. See 60, (a) with resistance, (b) unaided, (c) with a sling. 

Inward rotation of the humerus (twisting the arm in) : pectoralis major; 
deltoid (anterior); teres major; latissimus dorsi; subscapularis. 

Outward rotation of the humerus (twisting the arm out): teres minor; 
infraspinatus; deltoid (posteriori. 

Examination. — 61. The patient lies on the face with the arm stretched out side- 
ways at shoulder height, the forearm and hand hanging down over the edge of 




Fig. 1 10. — Examination No. 61, outward rotation of humerus. 



the table, so that the elbow is bent at a right angle. The surgeon steadies the 
upper arm and offers resistance against the ulnar side of the wrist while the 
patient raises the hand backward and upward, thus rotating the humerus 
inward; the surgeon then offers resistance against the radial side of the wrist 
while the patient raises the hand forward and upward, thus rotating the humerus 
outward. (See Fig. no.) 

The outward rotators, teres minor and infraspinatus, can easily be felt to 
contract by placing the fingers just below the spine of the scapula. They are 
assisted by the posterior fibers of the deltoid, the condition of which must be 



MUSCLE TRAINING 151 

taken into account. Even normal muscles can overcome only very slight resist- 
ance in these movements, as the leverage is very great. 

62. The patient lies on the back, the arm close to the side, the elbow bent at 
a right angle and the forearm resting across the body. He turns the arm out- 
ward, pivoting it on the elbow, which is kept at a right angle and then turns it in 
again. The first movement is a test for weak outward rotators, the second a test 
for weak inward rotators. 

Exercises. — The exercises are the same as the tests described (61 and 62). 

Elevation of the Shoulder. — The muscles are: trapezius; levator 
anguli scapulae; rhomboids. 

Examination. — 63. The patient sits and shrugs the shoulder while the surgeon 
offers resistance by pressing down from above. 

NECK 1 

Flexion of Head. — Sterno-mastoids (Piersol); omo-hyoids; sterno- 
hyoids; sterno-thyroids; mylo-hyoids; recti capitis antici, longus colli, 
other smaller muscles. 

Examination. — 64. The patient lies on the back, with the shoulders held down, 
and attempts to raise the head from the table. 

The sterno-mastoids are important muscles concerned in this movement. 
When they are seriously weakened the other muscles are apparently not strong 
enough to lift the head. 

65. The patient sits with the head hanging over backward and raises it to the 
vertical. This can probably be done without the sterno-mastoids. The exer- 
cises are the same as the tests (a) with resistance, (&) without. 

Extension of Head. — Trapezii (clavicular) (Piersol); splenii capitis; 
recti capitis postici; obliqui inferiores and others. 

Exarnination. — 66. The patient lies on the face, shoulders held down, and 
raises the head against resistance on the back of the head. 
The exercise is the same as the examination. 

Lateral Flexion of the Head. — 

Examination. — Many muscles take part in the movement, the sterno-mastoid 
being perhaps the most important. 

67. The patient lies on the unaffected side and attempts to raise the head 
laterally, (a) with resistance, (b) without. 

The exercise is the same as the examination. 
Rotation of the Head. — 

Examination. — A very complicated movement shared by many muscles. 

68. The patient sits with the face turned to one side and rotates the head to 
the opposite side against resistance. 

The exercise is the same as the examination. 

1 In the neck movements many muscles are involved and there is only partial 
agreement among anatomists as to their particular function. The list of muscles 
therefore given in this connection is of little value. 



CHAPTER VII 

THE SPRING BALANCE MUSCLE TEST 

At the time when the first series of Vermont observations was taken in 
January, 191 5, the examination of paralyzed and partly paralyzed mus- 
cles was made wholly by hand and it became evident at once that some 
quantitative method of estimating muscular strength was necessary for 
any accurate study or any conclusions of value to be drawn from such 
study. 

By manual examination the muscles could only be classed as normal, 
partly paralyzed or totally paralyzed. The first and the last class were 
clear enough, but in the "partly paralyzed" division we had to group 
muscles which were just short of normal and muscles which showed only a 
flicker of movement on attempted contraction. Between these two widely 
separated conditions existed every degree of disability, yet one must put 
them all in one class. Exact study of the phenomena under these condi- 
tions was impossible. 

Again, in the matter of treatment some scale of measuring improve- 
ment or the reverse was urgently needed. " Impressions " that electricity 
of one kind or another, or rest or exercise were beneficial have filled litera- 
ture; unsupported assertions, marvelous cures, fantastic treatments have 
too often been advanced on the slenderest of grounds. With the realiza- 
tion that partial paralysis was the usual form of affection, it became imper- 
ative to have some scale by which to work out what should be a precise 
and more accurate treatment. The muscle test to be described offers a 
practical quantitative scale by which the effects of modifications of treat- 
ment may be studied week by week and month by month. 

The problem was presented to Professor Cannon and Assistant Professor 
Martin of the Physiological Department of the Harvard Medical School 
and the latter worked out a system of muscular tests by means of the 
spring balance, which have proved reliable in practical use and which have 
been published. 1 

1 E. G. Martin and R. W. Lovett: " A Method of Testing Muscular Strength 
in Infantile Paralysis," "jour. A. M. A.," Oct. 30, 1915. 

R. W. Lovett: "The Treatment of Infantile Paralysis. The Newer Aspects 
of the Problem with Certain Conclusions Drawn from the Vermont Epidemic," 
"Jour. A. M. A.," June 26, 1915. 

R. W. Lovett and E. G. Martin: " Infantile Paralysis in Vermont. A Report 
of the Progress of Cases Between January, 1915, and July, 1915," "Vermont 
State Medical Journal," February, 191 6. 

R. W. Lovett and E. G. Martin: " Certain Aspects of Infantile Paralysis, with 
a Description of a Method of Muscle Testing," " Jour. A. M. A.," Mar. 4, 1916. 

R. W. Lovett and E. G. Martin: "The Muscle Test for Infantile Paraly- 
sis — a Description of the Technique," "Am. Journ. Orth. Surg.," July, 1916. 

152 



MUSCLE TEST I 53 

The method of testing was first tried out in the spring of 191 5 and was 
far enough advanced to be used in Vermont in the summer and autumn of 
191 5 by Professor Martin. By the spring of 19 16 there had accumulated 
13,000 observations in 400 series on 177 patients which have been 
published. The technique of the test will first be described. 



TECHNIQUE OF THE MUSCLE TEST 

It is designed to test, under conditions of constant position and leverage, 
by a series of spring balance pulls, the power of the muscles which govern 
the movement of the limbs. The value of the test consists in the possi- 
bility of duplicating exactly the conditions of the first test at succeeding 
ones so that a definite idea of gain or loss in muscular strength can be 
registered in pounds. It is applicable for all tests of power in normal 
muscles, for determining loss or gain in power at stated intervals, for 
the determination of the degree of initial weakness in paralyzed muscles, 
for determining the relative strength of the different muscles before 
tendon transplantation and similar operations. It has been applied for 
one year in consecutive tests varying in frequency from ten days to three 
months to infantile paralysis cases. The result has been an accurate 
register of general gain and occasional loss in the cases under treat- 
ment. The record has the advantage of representing concisely, in figures, 
the results of detailed muscular examination, and of presenting at 
later examinations the initial and intermediate conditions of the case. 

The method aims at pulling against a fixed position assumed by the 
patient rather than attempting to have the patient initiate a movement 
because it was found with children that they would hold a fixed posi- 
tion much more readily than they would initiate a muscular movement. 

The accuracy of the test depends upon the training of two persons, an 
operator and an assistant to coordinate the pull of the muscle and the 
registration of the pull on the scales, and upon the maintenance with exact- 
ness of the positions and leverage relationships outlined individually 
below. Accurate spring balance scales (No. 5) are used of four sizes: 1 to 
4 lb., graded in ounces; 1 to 30 lb.; 1 to 50 lb.; and 1 to 100 lb. The 
readings are taken to the half pound except on the ounce scale. [ The 
operator in general controls and maintains the correct position of the 
subject, stimulates the subject to innervation, braces and guides the limb 
tested, and calls the moment of give in the muscle tested through watch- 
ing the action of the muscle itself. The assistant makes the pull along 
lines accurately determined, beginning and stopping under the direction 
of the operator. The same command directs the muscular pull of the 
patient and the scale pull of the assistant. In all cases where the position 
of the assistant makes this possible, the scale reading is taken by him at 
the moment when the yielding in the muscle is called by the operator. 



154 



TREATMENT OF INFANTILE PARALYSIS 



Except under special circumstances, plantar flexion is the only reading 
which the operator is required to make. 

Twenty-two readings are taken, for each of which the best position of 
the subject for the accurate reading of the scales and for constant leverage 
in limb action has been determined experimentally. The order in which 
muscles are tested is immaterial except under conditions of weakness, but 
it is best that the order be constant so that all tests duplicate each other as 
completely as possible. The apparatus required is shown in the illus- 
tration (Fig. in) and referred to by the number on each piece, as they 
come into use in the description of the measurements themselves. 

In the lower extremity, the test records the following movements: 
plantar flexion, dorsiflexion, inversion, eversion, adduction, abduction, 




Fig. hi.- 



-Table and apparatus for use in muscle testing. The numbers are 
referred to in the text. 



hip extension, hip flexion, knee extension, knee flexion. The position of 
the operator and assistant in each movement is determined by their own 
convenience for fulfilling the other conditions of the test. The operations 
of these two individuals and the position and action required of the subject, 
for the measurement of these movements, are as follows: 

Plantar Flexion. — The subject lies on his back on a smooth table. The 
foot is braced against a three to one lever (No. i). The scale hook is 
inserted in the ring of the lever upright. The lever must be adjusted so 
that the ball of the foot in maximum plantar flexion rests squarely upon the 
lever pad (No. 2), with the upright at an angle of from 60 to 80 degrees to 
the table. The lever is held in position by C-clamps (No. 3). The pull is 
made by the assistant from the head of the table with the scale horizontal 



MUSCLE TEST 



155 



and in line with the leg being tested, and is increased in intensity to the 
point where the muscular resistance is overcome. To prevent slipping on 
the table, the shoulders of the subject are held by the hip-braces (No. 4). 
The muscle gives at about 45 degrees of plantar flexion with a rather sharp 
break in the resistance offered to the spring balance. All measurements of 
degrees are made to the plane of the table unless otherwise specified. 
The operator guides the position of the foot, stimulates the patient to 
innervation, and calls the moment of break in the muscle to the assistant 
for reading or reads the scale himself. The reading of the scale must be 
simultaneous with this break. 

Dorsal Flexion. — The general position of the subject is the same. The 
foot should be flush with the end of the table to give freedom of action to 




Fig. 112. — Muscle test for dorsal flexion of foot. 



the assistant in making the pull, and should be slightly lifted and braced 
by the hands of the operator which encircle the ankle. The leather loop 
(No. 6) is placed across the toes at their metatarsophalangeal joints. 
With the foot in maximum dorsiflexion, the assistant makes the pull at 
right angles to the plantar surface of the foot, lowering the scale to main- 
tain this angle as the foot gives. The muscle is watched by the operator 
and the moment when it gives called to the assistant who takes the scale 
reading. (Fig. 112.) 

Inversion. — Body position of the subject, the same as in dorsal flexion. 
The loop is across the inner surface of the great toe joint. The ankle is 
braced by the hands of the operator. With the foot at right angles to the 
leg, the foot is inverted and adducted as far as possible without inward 
rotation of the leg. The pull is opposite in direction to the muscular con- 



156 TREATMENT OE INFANTILE PARALYSIS 

traction, horizontal, and in the same vertical plane as the foot. The assist- 
ant swings the scale so as to maintain this relationship as the foot gives. 
The reading is taken by the assistant at the moment when the operator 
calls the break in resistance of the foot. 

Eversion. — General position as in dorsal flexion. Loop at the outer 
surface of the distal end of the fifth metatarsal. The foot is at right angles 
to the leg and is everted and abducted as far as possible without outward 
rotation of the leg. The pull is horizonta' and in the same vertical 
plane as the foot with a scale swing to maintain this position. The break 
is called and read as above. 

Adduction of the Leg. — No change in general body position of the sub- 
ject. Two hip-braces (No. 4) are placed in line with the crest of the ilium 
on each side of the pelvis and attached to the table with the C-clamps. 
With one hand in the popliteal space and the other below the heel, the 
operator gently supports the weight of the leg, raises the leg about 15 
degrees from the table, and maintains the foot vertical to prevent leg 
rotation. ) The subject contracts the inner muscles of the thigh so as to 
swing the leg inward across the median line about 15 or 20 degrees. This 
angle of contraction is a matter of comfort to the subject and varies with 
the individual. The angle of elevation of the leg from the table must be 
constant. The subject, during the pull, braces the trunk with the hands 
by pushing against the clamps of the hip-brace on the side opposite to that 
being tested. The loop is placed just above the internal malleolus. The 
pull is outward, horizontal, and at right angles to the leg. It must swing 
so as to preserve this angle as the leg gives. The operator calls for the 
reading as the leg becomes exactly parallel to the median plane of the 
body. This reading can be taken in the same fashion with the loop at the 
knee just above the patella. The power here, with allowance for the 
minor individual variations in leg length, doubles the ankle pull through 
halving the distance of the measuring spring balance from the fulcrum. 
The knee pull is used where the quadriceps is weak and it is difficult for 
the subject to maintain knee extension while making the adductor pull 
from the hip. 

Abduction of the Leg. — The details of position and bracing in this pull 
differ only in the direction of the muscular action which reverses the brac- 
ing and the positions of the operator and assistant. The loop is just 
above the external malleolus. The subject contracts the muscles which 
abduct the hip so as to swing the leg outward from the median plane at an 
angle of 30 or 40 degrees, according to individual comfort. The pull is 
inward, horizontal and at right angles to the leg. This angle and the 
angle of 15 degrees of leg elevation must be maintained constant through- 
out the pull, exactly as in adduction. The operator calls for the scale 
reading as the leg becomes parallel to the median plane. The test is 
made at the knee where the quadriceps is weak. 



MUSCLE TEST I 57 

Hip Extension. — The subject lies on the side opposite to that to be tested 
with the hips directly one above the other. The abdomen is braced 
against the hip-clamp used in abduction and adduction. At the lower 
end of the table, two C-clamps, across which a small board is placed for 
comfort, are used by the subject as a brace. He pushes against this with 
the foot of the leg not being tested to secure steadiness. The trunk is 
braced forward, by the subject, by holding to the edge of the table with 
the hands. The operator maintains the position of the abdomen against 
the hip-brace with one hand and with the other supports the weight of the 
leg to be tested and keeps the leg parallel to the table. The loop is at the 
knee across the popliteal space. The leg is placed in maximum extension 
with the knee straight. The direction of pull of the balance is slightly less 
than 90 degrees to the leg, being deflected toward the trunk, and is 
exerted horizontally. The angle of the pull must be constant throughout 
the movement. The operator calls for the reading as the leg crosses the 
line of the trunk, or if the muscle gives before this, the reading is taken 
when the muscle yields. 

Hip Flexion. — Side position and foot-brace as for hip extension. The 
small of the back is against the hip-brace. The subject maintains the 
rigidity of the trunk by pushing with the hands against the opposite hip- 
brace. The operator supports the leg parallel to the table with one hand 
at the knee and the other at the ankle. The loop is at the knee just above 
the patella. The knee is well bent, and the thigh is flexed above the right 
angle. The pull is horizontal and as near as possible at right angles to the 
femur. The reading is taken when the muscle gives. 

Knee Extension. — The subject lies on the face on the table with the 
lower leg flexed at the knee and vertical to the table. The loop is at the 
ankle just proximal to the malleoli. The assistant stands at the head of 
the subject bracing the shoulder with one hand. The pull is horizontal 
and parallel to the median plane. The operator braces the knee on the 
table with one hand and with the other at the ankle limits the extension. 
The movement begins from the perpendicular position, and the effort of the 
subject to extend the leg and the pull of the assistant must start simul- 
taneously at the command of the operator. Both pulls should begin 
slowly, and it is essential that the muscle pull and the pull of the spring 
balance should develop together in this test. The leg is not permitted to 
extend from the perpendicular position further than to within 75 degrees of 
the table. Greater extension than this changes the leverage and produces 
inaccuracy. The pull of the assistant continues until the knee is drawn 
back to the original position, the operator calling for the scale reading 
exactly as the leg crosses the perpendicular line. The quadriceps test 
is the most accurate of all tests to repetition, but also the most liable to 
error if over-extension is permitted before the balance pull begins to draw 
the leg back to the vertical position (Fig. 113). 



i5» 



TREATMENT OF INFANTILE PARALYSIS 



Knee Flexion. — General body position of the subject and brace by the 
operator the same. Ankle loop reversed in direction and assistant at the 
foot of the table. The subject places the leg in maximum flexion. The 
pull is horizontal and rotation of the hip should be minimized. The opera- 
tor calls for the scale reading as the leg passes the perpendicular position. 
If the reading is taken with the leg more than 15 degrees beyond the per- 
pendicular, accuracy is destroyed through change of leverage. 

This group of leg tests can be made in half an hour where the subject 
responds easily to directions and the operator and assistant are accustomed 
to coordinate work. Every reading is repeated as a check. The readings 
agree very closely unless there is an error in technique. In the first test 




Fig. 113. — Muscle test for knee extensors. 



the pull generally rises slightly on the repetition because the subject 
understands the requirements of the movement better the second time it 
is made. But in subsequent tests, the first reading is usually the better. 

In the upper extremity the test records the following movements: 
Pectoralis, latissimus dorsi, anterior deltoid, posterior deltoid, forearm 
extension, forearm flexion, wrist extension, wrist flexion, finger extension, 
finger flexion, thumb adduction, thumb abduction. In all the movements, 
the break is called by the operator and the scale read by the assistant. For 
the first four movements the loop is at the elbow just above condyles of the 
humerus. 

Pectoralis. — The subject stands or sits with the shoulders and the hips 
in the same vertical plane. If standing, he braces the thigh well against 
the table to prevent loss of balance. The arm is drawn as far as possible 



MUSCLE TEST I 59 

across the front of the body just clearing the trunk with the forearm in pro- 
nation. Any brace of the body with the opposite arm is permissible which 
does not disturb the plane of the shoulders and hips. The pull is hori- 
zontal and outward posteriorly at an angle of 30 degrees to the lateral 
plane of the body. 

Latissimus dorsi. — The subject stands or sits as above. The fist is 
closed and with the dorsum of the hand toward the back, the arm is 
drawn as far as possible^ across, behind the body, just clearing the trunk. 
The pull is horizontal and outward anteriorly at an angle of 30 degrees to 
the lateral plane. 

Anterior Deltoid. — Positions of the subject, the same. The opposite 
hand holds to any support which does not elevate the shoulders. The arm 
being tested is raised to the level of the shoulder, and brought forward to 
an angle 30 degrees from the lateral plane of the trunk. The pull is 
backward and downward, establishing an angle of 60 degrees with the 
upper arm and maintains this angle as the arm gives. 

Posterior Deltoid. — The subject stands or sits as in the other shoulder 
tests. The arm is raised to the level of the shoulder posteriorly at an angle 
of 30 degrees to the lateral plane of the trunk. The pull is forward and 
downward, establishing an angle of 60 degrees with the upper arm, and 
maintains this angle as the arm gives. 

Forearm Extension. — The subject lies on the back with the arm at the 
side and the forearm perpendicular to the table against which the elbow 
rests. The hand is closed with the thumb pointing to the shoulder. The 
loop is at the wrist just proximal to the styloid process of the ulna. The 
assistant stands at the head of the table and braces with one hand the 
shoulder of the side to be tested. The operator braces the elbow on the 
table with one hand and with the other at the wrist limits the extension of 
the forearm. The pull is horizontal. At the direction of the operator, the 
extension of the forearm and the pull of the assistant start together slowly. 
Extension is permitted to from 5 to 1 5 degrees from the perpendicular and 
is overcome by the assistant. The call for the reading of the scale is made 
just as the forearm crosses the vertical line. 

Forearm Flexion. — No change in the position of the subject nor the 
bracing of the operator. Loop just proximal to the styloid process of the 
radius. The forearm is placed in maximum flexion with the elbow on the 
table, the hand closed, and the thumb pointing toward the shoulder. 
When the muscular power requires it, the foot-brace described in hip 
extension is used in the same fashion by the subject to prevent slipping 
during the movement. The pull is horizontal. The operator calls for 
the scale reading as the forearm crosses the perpendicular line. 

Wrist Extension. — The subject extends the entire arm laterally and 
anteriorly according to individual comfort. With the palmar surface of 
the hand vertical and the fingers extended, the wrist is put in maximum 
extension. The operator encircles the wrist with his hands, bracing the 



l6o TREATMENT OE INFANTILE PARALYSIS 

subject's arm in the extended position. The small loop (No. 7) is across 
the dorsum of the hand just distal to the metacarpals. The pull is exerted 
horizontally and at an angle slightly less than 90 degrees to the hand, being 
deflected toward the wrist. The angle of pull must be constant and to 
secure this the assistant swings the scale through an arc as the hand gives. 
The accuracy of the reading depends absolutely upon maintaining the 
direction of the pull and upon the correct placing of the loop and is most 
important in this and the three following tests. 

Wrist Flexion. — With the arm well away from the side, the subject flexes 
the elbow according to comfort. With the fingers flexed at right angles 
to the palm, and the palmar surface of the hand in the vertical plane, the 
subject puts the wrist in maximum flexion. The small loop is across the 
palm at the crease formed by the finger flexion. The operator braces 
the wrist and arm in this position, encircling the wrist with both hands. 
The pull is horizontal and at an angle slightly less than 90 degrees to the 
dorsal surface of the hand. The angle of the pull must be maintained by 
an arc swing of the scales. 

Finger Extension. — The subject extends the arm as for wrist extension. 
The hip-brace is attached lengthwise to the side of the table. The palm 
of the hand well below the palmar crease is braced by the operator against 
the curved upright of the brace. The small loop is across the ringers dor- 
sally just proximal to the first interphalangeal joint. The pull is horizontal 
and at an angle slightly less than 90 degrees to the extended fingers and 
deflects toward the wrist. 

Finger Flexion. — The position of the subject and the brace by the opera- 
tor are the same. The small loop is placed across the fingers on the pal- 
mar surface just proximal to the first interphalangeal joint. The palmar 
surface of the hand is vertical against the brace. The pull is horizontal 
and slightly less than 90 degrees to the proximal phalanges. The deflec- 
tion is toward the dorsum of the hand. 

Thumb Adduction. — With the palmar surface down and the hand 
horizontal, the operator braces the extended fingers with one hand and 
the wrist with the other. The small loop is placed at the interphalangeal 
joint of the thumb. The subject adducts the thumb as far as possible 
under the palm. The pull is horizontal and at right angles to the thumb. 
The call for the reading is made by the operator just as the thumb appears 
from under the hand. 

Thumb Abduction. — General position of the hand and brace by the 
operator the same as for the preceding test. The subject abducts the 
thumb in the same horizontal plane as the hand. The position of the small 
loop is identical with that of adduction, but reversed in direction. The 
pull deflects downward from the horizontal just enough to escape the 
palmar surface of the hand. It is exerted at right angles to the thumb. 

The complete arm test requires half an hour and each reading is repeated 
as a check. 



INDEX 



D 



Abdominal paralysis, 39 
Acute phase, treatment of, 30 
Ambulatory treatment, 38 
Apparatus, 42 

disadvantages of, 48 

summary, 48 
Arthrodesis, 107 

of ankle, 107 

of elbow, 109 

of hip, 109 

of knee, 108 

of shoulder, 109 

Jones' operation, no 

substitutes for, 109 
Astragalectomy, 118 



Davis' operation for calcaneus, no 
Deformity, early, 35 

correction of, 75 

of ankle, 76 

of foot, 78 

of knee, 79 

of hip, 84 

of upper extremity, 94 

prevention of permanent, 52 

stages of, 53 

varieties of, 54 
Dislocation of hip, 61-122 
Dislocations, 61 
Diagnosis, 15 
Distribution, 7 



B 



E 



Bade's ivory peg for ankle fixation, Electricity, 70 

no Equinus, correction, 76 

Balance, 49 deformity, summary, 122 

Biesalski's operation for ankle fixa- 
tion, in F 
Braces for walking, 42 

Fatigue, 65 
C Flexion of hip, 122 



Calcaneus deformity, 102 

Hoffa's operation, 121 

Jones' operation, 121 

summary, 122 
Caliper splint, 45 
Capsule reefing, Jones, 121 
Chronic phase, 74 
Circulation, disturbance of, 11 
Codivilla's operation at ankle, no 
Contractions, prevention of, 35 
Convalescent phase, 38 
Cramer's operation for foot drop, 
109 



Gait, 123 

Gastrocnemius paralysis, 46 



H 



Heat, 69 

Hip, dislocation of, 122 
fasciotomy of, 86 
flexion deformity of, 84 

Hoffa's operation for foot drop, 109 
for calcaneus, 121 



161 



I 62 INDEX 

Hyperextension of knee, 122 

I 
Improvement, spontaneous, 19 

J 



Jones' operation for calcaneo-cavus, 
no 
for calcaneus, 121 



Pathology, 2 
Prognosis, 18 

effect of treatment on, 24 

operative, 28 



Quarantine, 34 



Q 



K 

Knee flexion, 79 

summary, 122 
hyperextension of, 82 
Knock knee, 81, 122 



Lameness, 75, 123 

Lexer's bone peg for ankle fixation, 

no 
Location, 7 



M 



Massage, 68 
Mortality, 14 

Muscle test, spring balance, 152 
training, 73, 123 

lower extremity, 129 

neck, 151 

spine, 140 

upper extremity, 142 
Muscles, examination of, 123, 126 
exercises for, 127 



N 



Nerve transplantation, 105 
Neurotization of muscles, 107 



Operative treatment, 75 
Operations to improve function, 96 
to improve stability, 107 



Recovery, 19 
Reflexes. 10 



Scoliosis, 57 

correction of, 88 
Sensation, disturbance of, 10 
Severity, 7 
Shortening, 74 

of tendons, 121 

prognosis of, 23 
Shoulder, dropping of, 122 
Silk ligaments, 112 

preparation of, 1 00 
Soutter's operation for hip flexion, 

86 
Spring balance muscle test, 152 
Symptoms, 4 



Tenderness, 33 
Tendon fixation, 116 

shortening, 121 

transplantation; 96 
Tenodesis, 116 
Transplantation of nerves, 105 

of tendons, 96 
Transverse section of foot for 

calcaneus, no 
Treatment, plan of, 29 
Trophic disturbances, 11 
Type, abortive, 11 

ataxic, 13 



INDEX 



163 



Type, bulbar, 13 

encephalitic, 13 

meningitic, 14 

polyneuritic, 14 

progressive, 12 

spinal, 6 
Types, 5 

V 

Valgus deformity, summary, 122 



Varus deformity, summary, 122 
Vibration, 69 

Vulpius' operation, fasciodesis 
109 

W 

Walking, instruction in, 50 

without braces, 41 
Whitman's operation, 118 
Wickman's classification, 5 



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